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The distribution of rural female generalist physicians in the United States

JOURNAL OF RURAL HEALTH 2000年第2期16卷 111-118页

作者： Doescher, MP Ellsbury, KE Hart, LG Univ Washington Dept Family Med Sch Med Seattle WA 98195 USA

Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of then most recent 10-year medical school graduation cohort of female generalist physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will nit be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.

关键词：美国医学协会卫生服务易得程度/统计学和数值数据缺医地区医师家庭/供应和分配医师女/供应和分配专业场所/统计学和数值数据乡村卫生服务/人力美国女(雌)性人类男(雄)性

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Limited English proficiency and Latinos' use of physician services

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MEDICAL CARE RESEARCH AND REVIEW 2000年第1期57卷 76-91页

作者： Derose, KP Baker, DW Univ Calif Los Angeles RAND Hlth Santa Monica CA 90407 USA Case Western Reserve Univ Metro Hlth Med Ctr Cleveland OH 44106 USA

Many Latinos have limited English proficiency and this may negatively affect their use of health care services. To examine this, the authors interviewed 465 Spanish-speaking Latinos and 259 English speakers of various ethnicities who presented to a public hospital emergency department with nonurgent medical problems to assess previous physician visits, sociodemographic characteristics, and level of English proficiency. The proportion of patients who reported no physician visit during the 3 months before study enrollment was not related to English proficiency. However, among the 414 patients who saw a physician at least once, Latinos with fair and poor English proficiency reported approximately 22 percent fewer physician visits (p = 0.020 and p = 0.015, respectively) than non-Latinos whose native language was English, even after adjusting for other determinants of physician visits. The magnitude of the association between limited English proficiency and number of physician visits was similar to that for having poor health, no health insurance, or no regular source of care.

关键词：信息交流障碍急诊室医院/利用健康知识态度实践卫生服务易得程度/统计学和数值数据卫生服务研究西班牙裔美国人/心理学医院公立/利用洛杉矶模型心理学多元分析病人接受卫生保健的程度/人种学病人接受卫生保健的程度/统计学和数值数据问卷调查回归分析成年人女(雌)性人类男(雄)性

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Socioeconomic distress and health status: The urban-rural dichotomy of services utilization for people with sickle cell disorder in North Carolina

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JOURNAL OF RURAL HEALTH 2000年第1期16卷 43-55页

作者： Haque, A Telfair, J Univ Alabama Ctr Urban Affairs Birmingham AL 35294 USA Univ Alabama Div Social Hlth Serv & Community Based Res Ctr Comprehens Sickle Cell Birmingham AL 35294 USA

Research on sickle cell disorder has not focused attention on the socioeconomic background and geographic distribution of people with the disease. This study examines 1,189 persons with sickle cell disorder in North Carolina during 1991 to 1995. Three indices were developed using clients' medical psychosocial and socioeconomic characteristics for the purpose of analyzing the urban-rural difference in treatment for sickle cell disease. The study observed a wide disparity in these indices between urban and rural population groups. Also, differences were observed in the utilization of services and clients' health status. The findings suggest that utilization of services is directly related to socioeconomic condition facing clients and clinic distance from clients. They further suggest that people in rural areas who have high distress levels and are far from clinics have limited access to health care. The limited availability of medical and health care in rural areas, as well as other support systems calls for an increase in community based healthcare services. These findings should be of particular interest to the state level sickle cell disorder program in North Carolina and other areas with a large rural population. Enhanced support for all persons with sickle cell disorder in North Carolina particularly those in rural areas, is critical.

关键词：贫血镰状细胞性/治疗社区卫生服务/利用卫生服务易得程度/统计学和数值数据北卡罗来纳/流行病学贫困/统计学和数值数据回归分析农村卫生/统计学和数值数据疾病影响状态调查社会阶级城市卫生/统计学和数值数据青少年成年人儿童儿童学龄前女(雌)性人类婴儿男(雄)性

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What happens when capitated behavioral health comes to town? The transition from the Fort Bragg demonstration to a capitated managed behavioral health contract

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 2000年第4期27卷 390-405页

作者： Heflinger, CA Northrup, DA Vanderbilt Ctr Mental Hlth Policy Nashville TN USA

Capitated managed care contracts for behavioral health services are becoming more prevalent across the country in both public and private sectors. This study followed the transition from a demonstration project for child mental health services to a capitated managed behavioral health care contract with a for-profit managed care company. The focus of the study was on the impact-at both the service system and the individual consumer level-pertaining to the start-up and maintenance of a capitated managed behavioral health program. A case study using multiple methods and multiple sources of information incorporated a program fidelity framework that examined micro to macro levels of program implementation. The findings of this study include the following: access to services decreased, the lengths of stay and average daily census in the more intensive levels of treatment declined, difficult-to-treat children were shifted to the public sector and ratings of service system performance and coordination fell.

关键词：青少年保健服务/统计学和数值数据按人收费费用分配/统计学和数值数据保健福利计划雇员卫生服务易得程度/标准卫生服务易得程度/统计学和数值数据管理医疗规划/经济学管理医疗规划/组织和管理管理医疗规划/标准管理医疗规划/统计学和数值数据精神卫生服务/经济学精神卫生服务/组织和管理精神卫生服务/标准精神卫生服务/统计学和数值数据北卡罗来纳卫生保健质量/标准卫生保健质量/统计学和数值数据回顾性研究利用情况审核/标准利用情况审核/统计学和数值数据青少年儿童人类

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Performance of a general location model with an ignorable missing-data assumption in a multivariate mental health services study

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STATISTICS IN MEDICINE 1999年第22期18卷 3123-3135页

作者： Belin, TR Hu, MY Young, AS Grusky, O Univ Calif Los Angeles Ctr Hlth Sci Deot Psychiat & Biobehavioral Sci Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Biostat Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Stat Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Sociol Los Angeles CA 90095 USA

In a study of the impact of case management teams in a publicly funded mental health programme, mental health patients were interviewed about a variety of outcomes suggestive of successful community adaptation, such as support from family and friends and avoidance of legal problems. Because outcome data were missing for a number of patients, a follow-up study was carried out to obtain this information form previous non-responders whenever possible. Because the data of interest were multivariate and included both continuous and categorical variables, a candidate approach for handling incomplete data in the absence of follow-up data would have been to fit a general location model, presumably with log-linear constraints on cell probabilities to avoid overfitting of the data. Here, we use available follow-up data to investigate the performance of a series of general location models with ignorable non-response. We note some problems with this approach and embed the discussion of this example in a broader consideration of the role of ignorable and non-ignorable models in applied research. Copyright (C) 1999 John Wiley & Sons, Ltd.

关键词：随访研究卫生服务易得程度/统计学和数值数据健康调查采访(主题) Markov链精神卫生服务/统计学和数值数据模型统计学蒙特卡罗法多元分析女(雌)性人类男(雄)性

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Variations in the use of cardiac procedures in the Veterans Health Administration

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AMERICAN HEART JOURNAL 1999年第4期137卷 706-713页

作者： Mirvis, DM Graney, MJ Univ Tennessee Dept Prevent Med Memphis TN 38105 USA Univ Tennessee Dept Med Memphis TN 38105 USA Dept Vet Affairs Med Ctr Memphis TN USA

Background Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability Methods Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. Results Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory For undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. Conclusions Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

关键词：血管成形术经腔经皮冠状动脉/利用置信区间冠状动脉分流术/利用卫生服务易得程度/统计学和数值数据心脏导管插入术/利用医院退伍军人/统计学和数值数据医院退伍军人/利用 Logistic模型病案心肌缺血/外科学比值比医师诊疗模式/统计学和数值数据美国美国退伍军人事务部利用情况审核/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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The struck-off mystery

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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE 1999年第11期92卷 608-608页

作者： McKinley, RK Dixon-Woods, M Univ Leicester Leicester Gen Hosp Dept Gen Practice & Primary Hlth Care Leicester LE5 4PW Leics England Univ Leicester Dept Epidemiol & Publ Hlth Leicester LE1 6TP Leics England

Observations on ward rounds suggested that psychiatric patients might be at special risk of removal from their general practitioner's list. Little has been published on why patients are struck off and our first attempt at investigation was by direct appeals for patients. This drew a small and unsatisfactory sample. We then asked two family health services authorities to distribute questionnaires to struck-off patients. One agreed, but later withdrew cooperation. There is a danger that struck-off patients will become an underclass excluded from primary care. We propose anonymous collection of information by health authorities, so that policy can be reviewed if necessary.

关键词：社区精神病学/组织和管理数据收集/方法英格兰家庭医学/组织和管理卫生服务易得程度/统计学和数值数据医生病人关系诊疗准则(主题) 医生拒绝医治/统计学和数值数据人类

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Service components of case management which reduce inpatient care use for persons with serious mental illness

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COMMUNITY MENTAL HEALTH JOURNAL 1999年第2期35卷 153-167页

作者： Kuno, E Rothbard, AB Sands, RG Univ Penn Sch Social Work Philadelphia PA 19104 USA

This is a study of two types of case management: case management (CIM) which provided the service coordination functions, and Intensive Case Management (ICM) which consisted of both the coordination function and the provision of direct support to the client. Using secondary data on public clients, characteristics of mental health service use were analyzed for 80 ICM and 84 CM clients. The ICM clients had significantly fewer episodes per patient and less inpatient days per year than the CM clients. These findings suggest that direct support services make a significant difference in reducing annual hospital care.

关键词：病例管理/统计学和数值数据慢性病社区精神卫生服务/利用卫生服务易得程度/统计学和数值数据情绪障碍/流行病学情绪障碍/康复病人再入院/统计学和数值数据费城精神分裂症/流行病学精神分裂症/康复市区人口利用情况审核青少年成年人女(雌)性人类男(雄)性中年人

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The horizontal equity of health care in New Zealand

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AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999年第2期23卷 126-130页

作者： Peacock, D Devlin, N McGee, R Univ Otago Dept Prevent & Social Med Dunedin New Zealand Univ Otago Dept Econ Dunedin New Zealand

Objective: Given that 'equal access for equal need' is a clearly articulated goal of the New Zealand public health system, this study is an attempt to determine if access to public health care services in New Zealand is, for people of equal health need, independent of income. Method: Information on health status, income and health service utilisation for just over 6,000 New Zealanders was obtained from the national Household Health Survey 1992-93. Using standardised expenditure concentration curves and a concentration index, the distribution of health service use by individuals in different income groups, as a proxy for access, was illustrated and quantified. Results: The results suggest either appropriate or slightly excess use of services by the poor given their estimated health need. Due to analytical problems caused by data deficiencies, these results must be regarded as tentative. Conclusion: For the period under study, no evidence was found to indicate significant access barriers to publicly funded health care for people on different incomes. This study has served to demonstrate one approach to measuring inequality and analysing the relationship between inequality and inequity. Given the reforms to the health sector since 1993, ongoing monitoring of equity of access to health care services is essential. Implications: Given the income-related disparities in health that do exist, the public health community should endeavour to develop techniques to monitor the delivery of publicly funded health care to ensure that further inequity is not borne by the poor.

关键词：年龄因素卫生服务/利用卫生服务易得程度/统计学和数值数据卫生服务需求/统计学和数值数据健康调查新西兰结果评价(卫生保健)/统计学和数值数据危险因素社会正义社会经济因素青少年成年人老年人儿童女(雌)性人类男(雄)性中年人

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The Massachusetts Behavioral Health Program year 5: Transition to a new managed care organization

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ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 1999年第5期26卷 313-327页

作者： Beinecke, RH Keane, RJ Symanzick, M Casey, D Suffolk Univ Dept Publ Management Boston MA 02108 USA Boston Coll Sch Social Work Chestnut Hill MA 02167 USA

Year 5 of the Massachusetts Behavioral Health Program was a transition to management by a new private managed care organization. Fifty-eight providers interviewed for an ongoing panel survey reported slightly lower levels of quality, access, utilization, and length of stay than a year earlier. Relationships with providers and advocates improved after an initial difficult period, while consumer and family involvement at all levels remained low. The greatest changes in managed care appeared to take place during the initial transition from fee-for-service care, but intractable problems continue, and full participation of stakeholders seems difficult to achieve.

关键词：医务工作者的态度行为医学/组织和管理行为医学/发展趋势用户满意/统计学和数值数据合同业务/组织和管理卫生保健调查卫生服务易得程度/统计学和数值数据管理医疗规划/组织和管理管理医疗规划/标准管理医疗规划/利用马萨诸塞 Medicaid/组织和管理精神障碍/康复规划制订卫生保健质量/统计学和数值数据物质相关性障碍/康复美国人类

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