Affordable Care Act Impact on Community Health Center Staffing and Enrollment: A Cross-Sectional Study.

Over 500 000 Washingtonians gained health insurance under the Affordable Care Act (ACA). As more patients gain insurance, community health centers (CHCs) expect to see an increase in demand for their services. This article studies the CHCs in Washington State to examine how the increase in patients has been impacting their workload and staffing. We found a reported mean increase of 11.7% and 5.4% in new Medicaid and Exchange patients, respectively. Half of the CHCs experienced large or dramatic workload impact from the ACA. Our findings suggest that CHCs need further workforce support to meet the expanding patient demand.

Big Pharma on the Farm: Students Are Exposed to Pharmaceutical Marketing More Often in Rural Clinics.

BACKGROUND AND OBJECTIVES: Pharmaceutical marketing techniques are effective in changing the behavior of health care providers in ways that deviate from evidence-based practices. To mitigate the influence of pharmaceutical marketing on learners, academic medical centers (AMCs) have adopted policies to limit student/industry interaction. Many clinical experiences occur outside of the AMC. The purpose of this study was to compare medical students' exposure to pharmaceutical marketing in off-campus rural and urban underserved clinical sites. METHODS: The University of Washington School of Medicine Rural and Underserved Opportunities Program (RUOP) places rising second-year medical students in underserved clinical sites in five northwestern states. We surveyed RUOP students to evaluate their exposure to pharmaceutical marketing. RESULTS: Of 120 students, 86 (72%) completed surveys. Sixty-five (76%) did their RUOP rotation in rural areas. Students in rural locations were more likely to report exposure to pharmaceutical marketing. Distribution of free drug samples was reportedly three times higher in rural than urban sites (54% versus 15%). Doctors meeting with sales representatives were reported as four times higher in rural clinics (40% versus 10%). CONCLUSIONS: Students at rural sites reported exposure to pharmaceutical marketing more than those in urban settings. Rural medical educators should provide faculty development for community clinicians on the influences of pharmaceutical marketing on learners. Medical schools must review local clinic and institution-wide policies to limit pharmaceutical marketing exposure to learners in the rural learning environment.

Problem Drug-related Behavior and Discontinuation of Opioids Following the Introduction of an Opioid Management Program.

PURPOSE: Problem drug-related behavior (PDB) among patients on chronic opioid therapy may reflect an opioid use disorder. This study assessed PDB prevalence and the relationship between PDB and ongoing prescription of opioids at a primary care clinic that implemented a multifaceted opioid management program. METHODS: A chart review of patients in a chronic opioid registry assessed prevalence of different types of PDB over 2 years, and whether opioids were prescribed during the last 3 months of the 2-year study period among patients with different levels of PDB. RESULTS: Among 233 registry patients, 84.1% exhibited PDB; 45.5% exhibited ≥3 types of PDB. At the end of 2 years, most registry patients were still prescribed opioids, though patients with ≥3 types of PDB were less likely than those without PDB to be prescribed opioids (62.3% vs. 78.4%, P = 0.016). CONCLUSIONS: PDB was pervasive in this population of patients on chronic opioid therapy. Those with the most PDB, and thus with the greatest likelihood of opioid use disorder and its social and medical consequences, were the least likely to be prescribed opioids by the clinic after 2 years. Given the rising rates of illicit opioid use in the U.S., it is important that clinics work closely with their patients who display PDB, systematically assess them for opioid use disorder, and offer evidence-based treatment.

Geographic and specialty distribution of US physicians trained to treat opioid use disorder.

PURPOSE: The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS: We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS: Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS: In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder--particularly in rural America--is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

Barriers to primary care physicians prescribing buprenorphine.

PURPOSE: Despite the efficacy of buprenorphine-naloxone for the treatment of opioid use disorders, few physicians in Washington State use this clinical tool. To address the acute need for this service, a Rural Opioid Addiction Management Project trained 120 Washington physicians in 2010-2011 to use buprenorphine. We conducted this study to determine what proportion of those trained physicians began prescribing this treatment and identify barriers to incorporating this approach into outpatient practice. METHODS: We interviewed 92 of 120 physicians (77%), obtaining demographic information, current prescribing status, clinic characteristics, and barriers to prescribing buprenorphine. Residents and 7 physicians who were prescribing buprenorphine at the time of the course were excluded from the study. We analyzed the responses of the 78 remaining respondents. RESULTS: Almost all respondents reported positive attitudes toward buprenorphine, but only 22 (28%) reported prescribing buprenorphine. Most (95%, n = 21) new prescribers were family physicians. Physicians who prescribed buprenorphine were more likely to have partners who had received a waiver to prescribe buprenorphine. A lack of institutional support was associated with not prescribing the medication (P = .04). A lack of mental health and psychosocial support was the most frequently cited barrier by both those who prescribe and who do not prescribe buprenorphine. CONCLUSION: Interventions before and after training are needed to increase the number of physicians who offer buprenorphine for treatment of addiction. Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after they have completed their training, their clinical teams, and their administrations is likely to help more physicians become active providers of this highly effective outpatient treatment.

Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI program as a case study.

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation's most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals.The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

Treatment of early-stage prostate cancer among rural and urban patients.

BACKGROUND: Geographic barriers and limited availability of cancer specialists may influence early prostate cancer treatment options for rural men. This study compares receipt of different early prostate cancer treatments between rural and urban patients. METHODS: Using 2004-2006 SEER Limited-Use Data, 51,982 early prostate cancer patients were identified (T1c, T2a, T2b, T2c, T2NOS; no metastases) who were most likely to benefit from definitive treatment (< 75 years old, Gleason score < 8, PSA ≤ 20). Definitive treatment included radical prostatectomy, daily external beam radiation for 5 to 8 weeks, brachytherapy, or combination external beam radiation/brachytherapy. Adjusted definitive treatment rates were calculated by rural-urban residence overall, and for different sociodemographic and cancer characteristics, and different states based on logistic regression analyses, using general estimating equation methods to account for clustering by county. RESULTS: Adjusted definitive treatment rates were lower for rural (83.7%) than urban (87.1%) patients with early-stage prostate cancer (P ≤ .01). Rural men were more likely than urban men to receive non-definitive surgical treatment and no initial treatment. The lowest definitive treatment rates were among rural subgroups: 70 to 74 years (73.9%), African Americans (75.6%), American Indians/Alaska Natives (77.8%), single/separated/divorced (76.8%), living in New Mexico (69.3%), and living in counties with persistent poverty (79.6%). CONCLUSIONS: Between 2004 and 2006, this adjusted analysis found that men who were living in rural areas were less likely to receive definitive treatment for their early-stage prostate cancer than those living in urban areas. Certain rural patient groups with prostate cancer need particular attention to ensure their access to appropriate treatment. Rural providers, rural health care systems, and cancer advocacy and support organizations should ensure resources are in place so that the most vulnerable rural groups (men between 60 and 74 years of age; African American men; men who are single, separated, or divorced; and men living in rural New Mexico) can make informed prostate cancer treatment choices based on their preferences.

Who prescribes buprenorphine for rural patients? The impact of specialty, location and practice type in Washington State.

We determined the specialty, geographic location, practice type and treatment capacity of waivered clinicians in Washington State. We utilized the April 2011 Drug Enforcement Agency roster of all waivered buprenorphine prescribers and cross-referenced the data with information from the American Medical Association and online resources. Waivered physicians, as compared to Washington State physicians overall, are more likely to be primary care providers, be older, less likely to be younger than 35 years, and more likely to be female. Isolated rural areas have the lowest provider to population ratios. Ten counties lack either a buprenorphine provider or a methadone clinic. In rural areas, waivered physicians work predominately in federally-subsidized safety-net settings, which underscores the need for continued governmental support of primary care and mental health in these settings.

Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States.

The Pacific Northwest of the US is a large, sparsely populated region. A telehealth programme called Project ECHO (Extension for Community Health Outcomes) was tested in this region in 2009. Weekly videoconferences were held in the areas of hepatitis C, chronic pain, integrated addictions and psychiatry, and HIV/AIDS. Rural clinicians presented cases to a panel of experts at an academic medical centre and received management advice and access to best practices. During the trial, more than 900 clinicians participated, and more than 700 patient cases were presented. At the end of June 2012, a total of 23 videoconference clinics for hepatitis C had been held, 16 clinics in addiction and psychiatry, 97 in chronic pain and 13 in HIV/AIDS. The Project ECHO model improves access to health care. It may provide a way to bring specialist care to rural areas in developing countries.

Receipt of recommended radiation therapy among rural and urban cancer patients.

BACKGROUND: Rural populations have limited geographic access to radiation therapy. The current study examines whether rural patients with cancer are less likely than urban patients with cancer to receive recommended radiation therapy, and identifies factors influencing rural versus urban differences in radiation therapy receipt. METHODS: The current study included 14,692 rural and 107,834 urban patients with 5 cancer types and stages for which radiation therapy was recommended. The authors used 2000 to 2004 Surveillance, Epidemiology, and End Results (SEER) Limited-Use Data from 8 state-based (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Mexico, and Utah) and 3 county-based (Atlanta, rural Georgia, and Seattle/Puget Sound) cancer registries. Adjusted radiation therapy receipt rates were calculated by rural versus urban residence overall, for different sociodemographic and cancer characteristics, and for different states based on logistic regression analyses using general estimating equation methods to account for patient clustering by county. RESULTS: Adjusted rates of radiation therapy receipt were lower for rural (62.1%) than urban (69.1%) patients with breast cancer (P ≤ .001). Among patients with breast cancer, radiation therapy receipt differed more by sociodemographic characteristics (eg, rural patients aged < 50 years had a 67.1% receipt rate, whereas those aged ≥ 80 years had a radiation therapy receipt rate of 29.1%) than rural versus urban residence. Adjusted rates of radiation therapy receipt were similar for rural and urban patients with other cancer types overall (66.1% vs 68.2%; difference not significant), although there were differences between urban and rural patients with regard to radiation therapy receipt for patients with stage IIIA nonsmall cell lung cancer (66.2% vs 60.7%; P ≤ .01). CONCLUSIONS: Sociodemographics, cancer types and stages, and state of residence appear to have a greater influence over receipt of radiation therapy than rural versus urban residence location, suggesting that factors such as social support, receipt of other cancer treatments, and regional practice patterns are important determinants of radiation therapy receipt.

Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.

BACKGROUND: The introduction of buprenorphine as office-based treatment for opioid dependence was designed to expand treatment capacity, but virtually there are no data about use of this medication in rural areas. METHODS: The survey of the first cohort of physicians in rural Washington State who obtained buprenorphine waivers (2002-2010) to determine the volume of treated patients, physician appraisal of the efficacy of this treatment, and perceived barriers to treatment was conducted. Twenty-four (73 percent) of the 33 rural buprenorphine-certified physicians practicing in the state were interviewed in 2010. RESULTS: Twenty physicians (83 percent) were actively prescribing buprenorphine/naloxone for treatment of addiction. Those currently prescribing averaged 23 active patients and had treated 125 patients since certification. All respondents reported that buprenorphine was efficacious in the treatment of addiction and 95 percent recommended that other rural colleagues adopt buprenorphine treatment. The following four major barriers were cited: 1) lack of adequate financial support from Medicaid, the largest source of third-party coverage for these patients; 2) unavailability of local mental health and behavioral addiction treatment services; 3) difficulty in finding consultants to assist in managing complex patients; and 4) shortages of other rural physicians providing this service. CONCLUSIONS: Buprenorphine is viewed as a highly effective treatment of opioid addiction by early adopters in rural Washington State, but relatively few rural physicians currently provide this service. Inadequate insurance coverage, a shortage of effective links with consultants and colleagues, and the lack of mental health services are persistent barriers to the use of this modality in rural Washington State.

What can we learn from first-year medical students' perceptions of pain in the primary care setting?

OBJECTIVE: Pain concerns are one of the leading causes of visits to primary care. However, practicing physicians find managing pain frustrating and complex. There is little information about how undergraduate medical students approach pain and its management. This study aimed to explore first-year medical students' perceptions of pain-related patient encounters in the primary care setting. DESIGN: Qualitative analysis was used to explore first-year students' reflective journals written during an early clinical experience in primary care. Using iterative process for text analysis, entries referencing pain-related encounters were coded by two independent researchers with 94% inter-rater reliability. Themes and categories were sought by immersion crystallization. RESULTS: Three themes emerged from the students' journals: positive, negative, and neutral perceptions of pain-related encounters. With further analysis of the journals, acute, chronic, end-of-life, iatrogenic, and emotional pain categories also emerged. Most journal entries were negative, and chronic pain generated the most negativity. CONCLUSIONS: First-year medical students identified pain as a major concern in their early clinical experience. Students' perceptions of pain-related encounters can inform curriculum design and may ultimately benefit both physicians and the patients.

Commentary: do medical schools have a responsibility to train physicians to meet the needs of the public? The case of persistent rural physician shortages.

Persistent shortages of rural physicians have plagued the U.S. health care system for much of the last century. Recent, sharp declines in the number and proportion of U.S. medical students entering primary care have exacerbated this chronic problem because primary care physicians are the foundation of rural health care systems. The article by Chen and colleagues in the current issue of this journal replicates findings of a study 15 years ago by the author of this commentary and his colleagues that demonstrated that a relatively small number of medical schools are responsible for a large share of all of the rural physicians in the country. The lack of progress in the ensuing 15 years is distressing because there is now excellent evidence that targeted rural tracks in medical schools-including selective admissions of students from rural backgrounds and supportive integrated curricula-yield dramatic increases in the number of students choosing rural careers. U.S. medical schools-supported in large part by public funds-have a responsibility to ensure that the specialty choices and practice locations of their graduates meet the needs of the nation at large, as well as the rural and underserved communities in the regions they serve.

A longitudinal analysis of the general surgery workforce in the United States, 1981-2005.

HYPOTHESIS: The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. DESIGN: Retrospective longitudinal analysis. SETTING: Clinically active general surgeons in the United States. PARTICIPANTS: The American Medical Association's Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. MAIN OUTCOME MEASURES: Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. RESULTS: General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (-27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (-21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. CONCLUSIONS: The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

Will rural family medicine residency training survive?

BACKGROUND AND OBJECTIVES: Rural family medicine residencies may be more threatened by declining interest in family medicine than their urban counterparts. This study examines the recent performance of rural residencies in the National Resident Matching Program as an indicator of their viability. METHODS: We surveyed all 30 family medicine residencies located in rural areas during the summer of 2004 and a geographically matched sample of 31 urban residencies. We gathered information about the matching process for 2002, 2003, and 2004. The response rate was 70.5%. RESULTS: Rural programs offer about one third fewer first-year (postgraduate year 1 [PGY-1]) positions than their urban counterparts. Rural programs had lower Match rates (60.1%) than urban programs (72.5%) in 2004 but no meaningful differences in the proportion of international medical graduates (IMGs) or osteopathic physicians (DOs) who ultimately accepted positions. The 44.2% of residencies that predicted they would be thriving 2 years in the future filled an average of 81.3% of their slots on Match Day; there were no rural/urban differences. Programs with less-optimistic appraisals of their future had much lower Match rates. Two factors were associated with lower Match rates when other variables were taken into account: the proportion of IMGs in the 2 previous entering years and a stated rural mission. CONCLUSIONS: Rural programs appear to be slightly less stable than their urban counterparts, but the differences are minor. The viability of rural family medicine residency programs is probably affected more by the overall attractiveness of family medicine as a discipline rather than the rural or urban location of the residency.

The evolution of a required research program for medical students at the University of Washington School of Medicine.

The concepts and tools clinicians use to understand disease and treat patients are the direct product of basic and applied scientific inquiry. To prepare physicians to participate in this tradition of medical science, the University of Washington School of Medicine (UWSOM) created a research requirement in 1981. The objective was to provide students, during their clinical years of medical school, with first-hand experience in hypothesis-driven inquiry and an understanding of the philosophies and methods of science integral to the practice of medicine. A comprehensive curriculum review in 1998-2000 identified several limitations of this requirement. Although many students completed it successfully, others struggled to find mentors, funding, or time as coursework became more demanding. Other students found they had no interest in or aptitude for the research process itself. Accordingly, UWSOM has reaffirmed its commitment to independent inquiry but expanded the ways in which students can meet the requirement. Three research options are now available under the Independent Investigative Inquiry (III) program, generally completed the summer after students' first year of medical school. These are the hypothesis-driven inquiry, a critical review of the literature, or an experience-driven inquiry in community medicine. The goal of UWSOM is to shape new physicians who can manage rapidly changing medical science, information technology, and patient expectations in clinical practice and/or laboratories. The role of III is to teach students to develop personal methods of acquiring new knowledge and integrate it into their professional lives. Faculty support, program oversight, and funding have been increased.

Facilitating collaboration among academic generalist disciplines: a call to action.

To meet its population's health needs, the United States must have a coherent system to train and support primary care physicians. This goal can be achieved only though genuine collaboration between academic generalist disciplines. Academic general pediatrics, general internal medicine, and family medicine may be hampering this effort and their own futures by lack of collaboration. This essay addresses the necessity of collaboration among generalist physicians in research, medical education, clinical care, and advocacy. Academic generalists should collaborate by (1) making a clear decision to collaborate, (2) proactively discussing the flow of money, (3) rewarding collaboration, (4) initiating regular generalist meetings, (5) refusing to tolerate denigration of other generalist disciplines, (6) facilitating strategic planning for collaboration among generalist disciplines, and (7) learning from previous collaborative successes and failures. Collaboration among academic generalists will enhance opportunities for trainees, primary care research, and advocacy; conserve resources; and improve patient care.

Shortages of medical personnel at community health centers: implications for planned expansion.

CONTEXT: The US government is expanding the capacity of community health centers (CHCs) to provide care to underserved populations. OBJECTIVE: To examine the status of workforce shortages that may limit CHC expansion. DESIGN AND SETTING: Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia, conducted between May and September 2004. Questionnaires were completed by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative. MAIN OUTCOME MEASURES: Staffing patterns and vacancies for major clinical disciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment. RESULTS: Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equivalents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty filling positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities. CONCLUSIONS: CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.