National estimates of physician assistant productivity.

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.

Differences in fertility patterns between urban and rural women in Washington State, 1983-1984 to 1993-1994.

We use data on Washington State abortions and births for 1983-1984 and 1993-1994 to analyze trends for urban and rural women, using the demographic measures total abortion and total fertility rates. These express pacing of childbearing in a single number which is simple to calculate and interpret, and is age-standardized. We find significant urban-rural differences. Total abortion rates decline and total fertility rates increase in both areas. However, the relative magnitudes of pacing decreases in abortions for rural women and increases in births for urban women are striking. The demographic measures are useful interpretive tools, and can be applied to a broad range of questions.

Medical students' attitudes toward abortion and other reproductive health services.

BACKGROUND AND OBJECTIVES: The continued availability of legal abortions in the United States depends on the willingness of future physicians to provide this procedure. This paper explores the attitudes toward abortion issues of first- and second-year medical students at a large regional primary care-oriented medical school. METHODS: We anonymously surveyed 286 first- and second-year medical students at the University of Washington. RESULTS: The response rate to the written survey was 76.6%. Women were slightly overrepresented among the respondents. The majority of students supported the broad provision of reproductive health services; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Older students and women were more likely to support the provision of abortion services. CONCLUSIONS: Despite continuing pressure on abortion providers, most first- and second-year medical students at a fairly typical state-supported medical school intend to incorporate this procedure into their future practices.

PIP: This paper investigated the attitude toward abortion and other reproductive health services of first- and second-year medical students at the Seattle campus of the University of Washington, a large regional primary care-oriented medical school, in 1996-97. A total of 219 (76.6%) students responded. The majority of the students support the availability of a broad range of reproductive health services including abortion; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Moreover, older students and women were more likely to support the provision of abortion services. This study concludes that despite the continuing pressure on abortion providers, most first- and second-year medical students at a fairly state-supported medical school intend to incorporate this procedure into their future practices.

Dimensions of retention: a national study of the locational histories of physician assistants.

This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as "all rural," "all urban," "urban to rural" or "rural to urban." The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.

Abortion services in rural Washington State, 1983-1984 to 1993-1994: availability and outcomes.

CONTEXT: Fewer rural health providers offer abortion services than a decade ago. It is unknown how the reduction in service availability has affected women's pregnancy outcomes, the extent to which they must travel to obtain an abortion or whether abortions are delayed as a result. METHODS: Population, birth and fetal death data, as well as pregnancy termination reports, obtained from Washington State were used to calculate abortion rates and ratios and birthrates for Washington residents in 1983-1984 and in 1993-1994. Residence of abortion patients was classified by county only, and location of providers was recorded as large urban county, small urban county, large rural county or small rural county. Distances that women traveled to obtain an abortion were calculated. Chi-square tests were used to compare urban and rural rates and ratios within time periods, and to compare changes that occurred between time periods. RESULTS: Birthrates and abortion rates decreased for both rural and urban Washington women between 1983-1984 and 1993-1994, but the magnitude of the decrease was greater for rural women. The rural abortion rate fell 27%, from 14.9 abortions per 1,000 women to 10.9 per 1,000, while the urban rate dropped 17%, from 21.8 to 18.2 per 1,000. The decline in the abortion rate was larger for adolescents than it was for other age-groups. In rural areas, the abortion rate decreased from 16.5 per 1,000 adolescents aged 10-19 in 1983-1984 to 10.8 per 1,000 in 1993-1994, while it declined from 23.3 per 1,000 to 16.9 per 1,000 in urban areas. From the earlier to the later time period, rural women traveled on average 12 miles farther each way to obtain an abortion, and the proportion who obtained the procedure in a rural county decreased from 25% to 3%. In the earlier time period, 62% of rural women traveled 50 miles or more to obtain an abortion, compared with 73% in 1993-1994. From 1983-1984 to 1993-1994, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. The proportion of rural women terminating their pregnancy after the first trimester increased from 8% in 1983-1984 to 15% in 1993-1994. CONCLUSION: Rural Washington women are traveling farther and more often to urban and out-of-state locations for abortion services, and are obtaining their abortions at a later gestational age, which is associated with a decade-long decline in the number of abortion providers.

PIP: The availability and outcome of abortion services as of 1983-84 and 1993-94 in rural Washington State were investigated. The population data include birth, fetal death and pregnancy termination which came from the vital statistics data compiled by Washington State. Results showed that birth rates and abortion rates decreased throughout the state from 1983-84 to 1993-94. The magnitude of the drop in abortion rates was significantly greater in rural than in urban women (p 0.01). The rural abortion rate fell 27% compared with a 17% drop in the urban rate. The declination in the abortion rate was larger for adolescents than other age groups. The abortion rate for adolescents aged 10-19 years dropped 35% in rural areas and 28% in urban areas. 12 miles increased the distance that rural women traveled to obtain abortion. The proportion of rural women having abortions decreased significantly from 25% to 3%. During 1983-84, 62% traveled 50 miles to obtain abortion compared with 73% in 1993-94. In both time periods, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. Furthermore, the proportion of women terminating their pregnancy after the first trimester increased from 8% in 1983-84 to 15% in 1993-94. More work is needed to understand the relationships among provider availability, other factors influencing decision-making and pregnancy outcomes.

The effect of expanding Medicaid prenatal services on birth outcomes.

OBJECTIVES: Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates. METHODS: The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. RESULTS: The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washington's low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorado's rate increased slightly (10.4% to 10.6%, P = .74). Washington's improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions. CONCLUSIONS: A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Is non-metropolitan residence a risk factor for poor birth outcome in the U.S.?

The association between non-metropolitan residence and the risk of poor birth outcome in the United States was examined using the records of 11.06 million singleton births in the United States between 1985 and 1987. Rates of neonatal and post-neonatal death, low birth weight and late prenatal care among non-metropolitan residents were compared to the rates among metropolitan residents. The association between residence in a non-metropolitan area and the risk of poor birth outcome was assessed in national and state level regression analyses. Residence in a non-metropolitan county was not found to be associated with increased risk of low birth weight or neonatal mortality at the national level or in most states, after controlling for several demographic and biological risk factors. Non-metropolitan residence was associated with greater risk of post-neonatal mortality at the national level. Non-metropolitan residence was strongly associated with late initiation of prenatal care at both the national level and in a majority of the states. Residence in non-metropolitan areas does not appear to be associated with higher risk of adverse birth outcome. Regionalization of perinatal care and other changes in the rural health care system may have mitigated the risk associated with residing in areas relatively isolated from tertiary care. High levels of late prenatal care among non-metropolitan residents suggest a continuing problem of access to routine care for rural women and their infants that may be associated with higher levels of post-neonatal mortality and childhood morbidity.

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.

The regionalization of perinatal care in Wales and Washington State.

OBJECTIVES: The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State. METHODS: The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals. RESULTS: Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings. CONCLUSIONS: Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.

Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians.

BACKGROUND: This report addresses the long-term career paths and retrospective impressions of a cohort of family physicians who served in rural National Health Service Corps (NHSC) sites in return for having received medical school scholarships during the early 1980s. METHODS: We surveyed all physicians who graduated from medical school between 1980 and 1983, received NHSC scholarships, completed family medicine residencies, and served in rural areas. Two hundred fifty-eight physicians responded to our survey with complete information, 76 percent of the members of the cohort who could be located and met the study criteria. RESULTS: In 1994 one quarter of the respondents were still practicing in the county to which they had been assigned by the NHSC, an average of 6.1 years after the end of their obligation. Another 27 percent were still in rural practice. Of the entire group, less than 40 percent were in traditional urban private or managed care settings. CONCLUSIONS: Although only one quarter of NHSC assignees remain long term in their original assignment counties, they provide a large (and growing) amount of nonobligated service to those areas. Of those who leave, many remain in rural practice or work in community-oriented urban practices.

A comparison of the investment in hospital-based obstetrical ultrasound in Wales and Washington state.

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines--approximately two machines per 1,000 births--was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

Rural physician assistants: a survey of graduates of MEDEX Northwest.

Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural- and urban-practicing physician assistants are remarkably similar in most respects--income, hours worked, levels of practice satisfaction, for example--those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants.

The diffusion of obstetric technology into rural U.S. hospitals.

We determined the distribution and sophistication of obstetric technologies in all 80 maternity hospitals in the state of Washington and examined the effect of rural or urban location, birth volume, and physician staffing on technological intensity. Although smaller and more rural hospitals refer most premature and low-birth-weight infants to regional referral centers, sophisticated prenatal and intrapartum technologies are available in the majority of even the smallest and most remote rural units. Rural hospitals have slightly lower obstetrical intervention rates than do their urban counterparts, but the differences are not great.

Rural residence and poor birth outcome in Washington state.

It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome.

Readmission after surgery in Washington State rural hospitals.

BACKGROUND: Because of concern about the quality of care in rural hospitals, we examined readmission following four surgical procedures commonly performed in Washington State rural hospitals: appendectomy, cesarean section, cholecystectomy, and transurethral prostatectomy. METHODS: In a retrospective cohort study, we identified all patients discharged after receiving one of the foregoing procedures using the statewide hospital discharge database. Readmissions to any hospital in the state within 7 or 30 days of discharge were also identified. RESULTS: During the 2-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals, although the readmission rates for all four procedures were nominally lower in rural hospitals. Logistic regression analyses that controlled for factors that influence readmission did not change these results. CONCLUSIONS: Investigating readmission rates following common surgeries, we found no evidence of low-quality surgical care in Washington State rural hospitals. Early readmission is an imperfect marker for poor surgical outcome, however, and other proxies for quality remain to be examined.

Characteristics of physicians with obstetric malpractice claims experience.

This study compared the demographic and practice characteristics of physicians with and without obstetric malpractice experience. The sample consisted of 387 family physicians and 204 obstetricians in Washington state who were insured for obstetrics by a major malpractice carrier between January 1982 and June 1988. Fifty-three physicians (9%) had an obstetric malpractice claim during the study period. The approximate overall rate of obstetric malpractice claims was low: 0.32 per 1000 deliveries. The higher the total delivery volume (exposure), the greater the chance of having malpractice experience. Although physicians with practices of over 200 deliveries per year were more likely to have had malpractice experience, their risk of malpractice experience per delivery was lower than that of providers doing fewer than 200 deliveries per year. Our work suggests that insurers might consider basing obstetric malpractice premiums on numbers of deliveries rather than specialty.

Comparison of Transgrow and Gonozyme for the detection of Neisseria gonorrhoeae in mailed specimens.

The Transgrow culture system and Gonozyme (Abbott Laboratories, North Chicago, Ill.), an enzyme-linked immunosorbent assay procedure, were compared by examining 510 patients (320 females, 190 males) from whom duplicate genital swabs were obtained for the diagnosis of Neisseria gonorrhoeae infection. Both Transgrow and the Gonozyme swabs were mailed to the laboratory. Clinical, epidemiological, and laboratory data for the 30 specimens for which there were discrepancies were evaluated to determine the probability of gonorrhea. At the same time, Gonozyme was compared to on-site Thayer-Martin cultures from 258 of the 510 patients, with a 93% agreement. When sensitivity and specificity were calculated on the basis of clinical, epidemiological, and on-site laboratory data, Gonozyme had a sensitivity of 95% and a specificity of 99%. Transgrow culture was considered to have a 100% specificity and a sensitivity of 69%. Gonozyme appeared to be a superior method for the diagnosis of gonorrhea by means of mailed specimens.