Rural-Urban Differences in Access to Specialist Providers of Colorectal Cancer Care in the United States: A Physician Workforce Issue.

IMPORTANCE: Although early detection and treatment of colorectal cancer has been shown to improve outcomes, geographic proximity may influence access to these services. OBJECTIVE: To examine the disparities that may exist in colorectal cancer screening and treatment by comparing the distribution of providers of these services in rural and urban counties in the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective population-based study using data obtained from the 2009 Area Resource File for the entire US population within each county. MAIN OUTCOMES AND MEASURES: Counties in the United States were categorized as rural or urban using rural-urban continuum codes as our primary exposure. The proportion of gastroenterologists, general surgeons, and radiation oncologists per 100,000 people in each county was estimated as primary outcomes. Multivariate linear regression analysis adjusted for county-level socioeconomic variables, such as percentages of females, blacks, population without insurance, those with a high school diploma, and median household income, to estimate the relative density of each category of these providers between urban and rural counties. RESULTS: In total, 3220 counties were identified, comprising 1807 rural and 1413 urban counties. An unadjusted analysis showed an increased density of gastroenterologists, general surgeons, and radiation oncologists per 100,000 people in urban vs rural counties. A multivariable analysis revealed a significantly higher density of gastroenterologists (1.63; 95% CI, 1.40-1.85; P < .001), general surgeons (2.01; 95% CI, 1.28-2.73; P < .001), and radiation oncologists (0.68; 95% CI, 0.59-0.77; P < .001) per 100,000 people living in urban vs rural counties. CONCLUSIONS AND RELEVANCE: A rural-urban disparity exists in the density of gastroenterologists, general surgeons, and radiation oncologists who traditionally provide colorectal cancer screening services and treatment. This might affect access to these services and may negatively influence outcomes for colorectal cancer in rural areas.

Risk factors associated with lung retransplantation: evaluation of a nationwide registry over a quarter century.

BACKGROUND: The relative paucity of donors heightens the debate and scrutiny surrounding retransplantation. To date, risk factors associated with retransplantation are poorly characterized in the literature. We sought to identify those risk factors that may independently serve to predict lung retransplantation. METHODS: We performed a retrospective evaluation of the United Network for Organ Sharing data over 25 years from 1987 to 2012. Competing risk analysis was used to evaluate the cohort for cumulative incidence of retransplantation. Recipient-related, donor-related, and transplant-related characteristics were assessed using Cox regression to identify risk factors associated with lung retransplantation. RESULTS: We identified 23,180 adult lung transplant recipients, of which 791 (3.4%) had also undergone retransplantation. Factors associated with lung retransplantation at 1 year included recipient age (hazard ratio [HR], 0.97; p=0.005), admission to the intensive care unit (HR, 2.89; p=0.002), donor age (HR, 1.02; p=0.004), and bilateral lung transplantation (HR, 0.41; p<0.001). Moreover, predictors of 5-year risk of retransplantation included recipient age (HR, 0.95; p<0.001), intensive care unit hospitalization (HR, 1.87; p=0.005), and bilateral lung transplant (HR, 0.46; p<0.001), as well as recipient body mass index of 25 to 29 kg/m2 (HR, 1.29; p=0.04) and a diagnosis of chronic obstructive pulmonary disease (HR, 0.68; p=0.008). CONCLUSIONS: We identified factors associated with retransplantation that may afford a better prediction of graft failure and need for retransplantation. These may further serve to better guide donor selection and assist in the development and validation of a risk-scoring model to further guide preoperative counseling.

Medical students' participation in the 2009 Novel H1N1 influenza vaccination administration: policy alternatives for effective student utilization to enhance surge capacity in disasters.

As cases of 2009 novel H1N1 influenza became prevalent in Cincinnati, Ohio, Hamilton County Public Health called upon the University of Cincinnati College of Medicine to enhance its surge capacity in vaccination administration. Although the collaboration was well organized, it became evident that a system should exist for medical students' involvement in disaster response and recovery efforts in advance of a disaster. Therefore, 5 policy alternatives for effective utilization of medical students in disaster-response efforts have been examined: maintaining the status quo, enhancing the Medical Reserve Corps, creating medical school-based disaster-response units, using students within another selected disaster-response organization, or devising an entirely new plan for medical students' utilization. The intent of presenting these policy alternatives is to foster a policy dialogue around creating a more formalized approach for integrating medical students into disaster surge capacity-enhancement strategies. Using medical students to supplement the current and future workforce may help substantially in achieving goals related to workforce requirements. Discussions will be necessary to translate policy into practice.

Perspectives of future physicians on disaster medicine and public health preparedness: challenges of building a capable and sustainable auxiliary medical workforce.

BACKGROUND: Although the training of future physicians in disaster preparedness and public health issues has been recognized as an important component of graduate medical education, medical students receive relatively limited exposure to these topics. Recommendations have been made to incorporate disaster medicine and public health preparedness into medical school curricula. To date, the perspectives of future physicians on disaster medicine and public health preparedness issues have not been described. METHODS: A Web-based survey was disseminated to US medical students. Frequencies, proportions, and odds ratios were calculated to assess perceptions and self-described likelihood to respond to disaster and public health scenarios. RESULTS: Of the 523 medical students who completed the survey, 17.2% believed that they were receiving adequate education and training for natural disasters, 26.2% for pandemic influenza, and 13.4% for radiological events, respectively; 51.6% felt they were sufficiently skilled to respond to a natural disaster, 53.2% for pandemic influenza, and 30.8% for radiological events. Although 96.0% reported willingness to respond to a natural disaster, 93.7% for pandemic influenza, and 83.8% for a radiological event, the majority of respondents did not know to whom they would report in such an event. CONCLUSIONS: Despite future physicians' willingness to respond, education and training in disaster medicine and public health preparedness offered in US medical schools is inadequate. Equipping medical students with knowledge, skills, direction, and linkages with volunteer organizations may help build a capable and sustainable auxiliary workforce.

Residential segregation and access to surgical care by minority populations in US counties.

BACKGROUND: Minority groups in the US have comparatively poorer access to a range of health care services. Access can be considered a function of opportunity and use and can vary with the level of segregation within a county. We hypothesized that with varying levels of segregation, increasing the proportion of the minority population within a county was accompanied by decreasing levels of access to surgical care. STUDY DESIGN: A cross-sectional analysis was performed on data from the 2004 Area Resource File. Each county in the US was categorized into one of three levels: most, moderately, or least segregated, using the Isolation Index. Multivariable linear regression analysis was performed to examine the association between access to surgical services and proportion of minority population with varying levels of segregation adjusting for socioeconomic and health characteristics. RESULTS: In the most segregated counties, each percentage point increase in Hispanic or African-American population was associated with a statistically significant decrease in outpatient surgery volume (p < 0.0001), ambulatory surgical facilities (p < 0.0001), and number of general surgeons (p < 0.0001). In the least segregated counties, these associations showed no statistical significance. A significant increase (p < 0.0001) in the volume of emergency medical visits was associated with increasing proportions of African-American and Hispanic populations within the most segregated counties. CONCLUSIONS: In the most segregated counties, an increase in the African-American or Hispanic population was associated with a decrease in the availability and use of surgical services and an increase in emergency visits after adjustment for socioeconomic and health characteristics.

Racial clustering and access to colorectal surgeons, gastroenterologists, and radiation oncologists by African Americans and Asian Americans in the United States: a county-level data analysis.

BACKGROUND: Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level. DESIGN: A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists. SETTING: All counties in the United States. PARTICIPANTS: Prevalence rate of African Americans and Asian Americans within a county. MAIN OUTCOME MEASURE: Rate of colorectal surgeons, gastroenterologists, and radiation oncologists. RESULTS: Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13). CONCLUSION: Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.