Education and referral criteria: impact on oncology referrals to palliative care.

OBJECTIVE: To describe a quality improvement project involving education and referral criteria to influence oncology provider referrals to a palliative care service. METHODS: A single group post-test only quasi-experimental design was used to evaluate palliative care service (PCS) referrals following an intervention consisting of a didactic presentation, education outreach visits (EOV) to key providers, and referral criteria. Data on patient demographics, cancer types, consult volume, reasons for referral, pre-consult length of stay, overall hospital stay, and discharge disposition were collected pre-intervention, then post-intervention for 7.5 months and compared. SETTING AND SAMPLE: Attending oncologists, nurse practitioner, and house staff from the solid tumor division at a 700-bed urban teaching hospital participated in the project. Two geriatricians, a palliative care nurse practitioner, and rotating geriatric fellows staffed the PCS. RESULTS: The percentage of oncology referrals to PCS increased significantly following the intervention (χ(2) = 6.108, p = .013). 24.9% (390) patients were referred in the 4.6 years pre-intervention and 31.5% (106) patients were referred during 7.5 months post-intervention. The proportion of consults for pain management was significantly greater post-intervention (χ(2) = 5.378, p = .02), compared to pre-intervention, when most referrals were related to end-of-life issues. Lung, pancreatic, and colon were the most common cancer types at both periods, and there were no significant differences in patient demographics, pre-referral length of hospitalization or overall hospital days. There was a trend toward more patients being discharged alive following the intervention. CONCLUSION: A quality improvement project supported the use of education and referral criteria to influence both the frequency and reasons for palliative care referral by oncology providers.

Retention of rural family physicians after 20-25 years: outcomes of a comprehensive medical school rural program.

BACKGROUND: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of comprehensive medical school rural programs that has been successful in increasing the supply of family physicians practicing in rural areas. Although retention is a critical component of the rural physician supply, published long-term outcomes are limited. METHODS: Of the 1937 JMC graduates from the classes of 1978 to 1986, we identified those who were practicing family medicine in a rural county when they were first located in practice (in 1986 for 1978-1981 graduates and in 1991 for 1982-1986 graduates). Using the Jefferson Longitudinal Study, we then compared the numbers of PSAP and non-PSAP graduates who were still practicing family medicine in the same area in 2011. RESULTS: Of the 92 JMC graduates initially practicing rural family medicine, 90 were alive in 2011, and specialty and location data were available for 89 (98.9%). Of the 37 PSAP graduates who originally practiced rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 compared with 24 of 52 non-PSAP graduates (46.2%; P = .02). CONCLUSION: This study provides additional support for the substantial impact of medical school rural programs, suggesting that graduates of rural programs are not only likely to enter rural family medicine but to remain in rural practice for decades.

The relationship between matriculating medical students' planned specialties and eventual rural practice outcomes.

PURPOSE: To analyze the previously unknown relationships between the specialty plans of entering medical students and their eventual rural practice outcomes. METHOD: For 5,419 graduates from the 1978-2002 classes of Jefferson Medical College, their self-reported specialty plans at the time of matriculation were obtained from the Jefferson Longitudinal Study, as were their 2007 practice locations. Specialty plans were grouped into 12 categories, and the percentages of graduates initially planning each specialty group who were actually practicing in rural areas were determined. RESULTS: Entering medical students' specialty plans were strongly related to eventual rural practice (P < .001). Those students planning family medicine were "highly likely" to practice in rural areas (29.4%, 238/810). They were 1.5 times as likely to practice rural as a "mid-likely" group (those planning general surgery, psychiatry, emergency medicine, general internal medicine, or one of the medical subspecialties: 19.6% [range 17.9%-21.0%], 229/1,167). Students planning family medicine were also 2.1 times as likely to practice rural as those students planning a "lower-likely" group (those planning general pediatrics, one of the surgical subspecialties, the hospital specialties of radiology, anesthesiology and pathology, and obstetrics-gynecology, or other specialties: 14.0% [range 13.0%-14.3%], 142/1,016). CONCLUSIONS: These findings show that students' specialty plans at medical school matriculation are significantly related to rural outcomes, and they provide new information quantifying the absolute and relative likelihood of those planning various specialties to enter rural practice. This information is particularly important for medical schools that have or plan to develop comprehensive rural programs.

The relationship between entering medical students' backgrounds and career plans and their rural practice outcomes three decades later.

PURPOSE: Although many studies have investigated predictors of physician practice in rural areas, few have accounted for the importance of physicians' backgrounds. This study analyzed the relationship between the backgrounds and future career plans of entering medical students and their rural practice outcomes. METHOD: For 1,111 graduates from Jefferson Medical College (JMC, classes of 1978-1982), three factors self-reported at matriculation and previously related to rural practice were obtained from the Jefferson Longitudinal Study of Medical Education: growing up rural, planning rural practice, and planning family medicine. Their 2007 practice location was determined to be in a rural versus nonrural area. Analyses of graduates with various numbers of predictive factors (0-3) and rural practice were performed. RESULTS: Of the 762 JMC graduates (69%) with complete data, 172 (23%) were practicing in rural areas. Of graduates with all three predictors, 45% (45/99) practiced in rural areas compared with 33% (48/145) of those with two predictors, 21% (42/198) with one predictor, and 12% (37/320) of those with none. Of physicians practicing in rural areas in 2007, only 22% had no predictors. CONCLUSIONS: Three factors known at the time of medical school matriculation have a powerful relationship with rural practice three decades later. Relatively few students without predictors practice in rural areas, which is particularly significant given subsequent factors known to be related to rural practice--for instance, rural curriculum, residency location, or spouse. These results have major implications for the role of the medical school admissions process in producing rural physicians.

Increasing the supply of women physicians in rural areas: outcomes of a medical school rural program.

BACKGROUND: Women physicians are less likely then men to practice in rural areas. With women representing an increasing proportion of physicians, there is concern that this could exacerbate the rural physician shortage. The Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) is one of a small number of medical school rural programs shown to be successful in addressing the rural physician shortage; however, little is known about their specific impact on women. METHODS: For 2394 physicians from the 1992 to 2002 JMC graduating classes, the 2007 practice location and specialty for PSAP and non-PSAP graduates were obtained from the Jefferson Longitudinal Study. The relative likelihood of PSAP versus non-PSAP graduates practicing in rural areas was determined for women and men and compared. RESULTS: Women PSAP graduates were more than twice as likely as non-PSAP women to practice in rural areas (31.7% vs 12.3%; relative risk, 2.6; 95% CI, 1.6-4.2). This was similar to the PSAP outcomes for men (51.8% vs 17.7%; relative risk, 2.9, 95% CI, 2.2-3.9; relative risk ratio, 0.9, 95% CI, 0.5-1.5). PSAP outcomes were also similar for women and men practicing rural family medicine and rural primary care. CONCLUSION: These results provide support that medical school rural programs have the potential to help address the serious shortage of women physicians in rural areas, thereby increasing access to care for those living there.

Family factors in end-of-life decision-making: family conflict and proxy relationship.

BACKGROUND: Few studies have examined proxy decision-making regarding end-of-life treatment decisions. Proxy accuracy is defined as whether proxy treatment choices are consistent with the expressed wishes of their index elder. The purpose of this study was to examine proxy accuracy in relation to two family factors that may influence proxy accuracy: perceived family conflict and type of elder-proxy relationship. METHODS: Telephone interviews with 202 community-dwelling elders and their proxy decision makers were conducted including the Life-Support Preferences Questionnaire (LSPQ), and a measure of family conflict, and sociodemographic characteristics, including type of relationship. RESULTS: Elder-proxy accuracy was associated with the type of elder-proxy relationship. Adult children demonstrated the lowest elder-proxy accuracy and spousal proxies the highest elder-proxy accuracy. Elder-proxy accuracy was associated with family conflict. Proxies reporting higher family conflict had lower elder-proxy accuracy. No interaction between family conflict and relationship type was revealed. CONCLUSIONS: Spousal proxies were more accurate in their substituted judgment than adult children, and proxies who perceive higher degree of family conflict tended to be less accurate than those with lower family conflict. Health care providers should be aware of these family factors when discussing advance care planning.

Moving from street to home: health status of entrants to a housing first program.

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors' evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs.

Increasing the supply of rural family physicians: recent outcomes from Jefferson Medical College's Physician Shortage Area Program (PSAP).

PURPOSE: The shortage of primary care physicians in rural areas is an enduring problem with serious implications for access to care. Although studies have previously shown that medical school rural programs-such as Jefferson Medical College's Physician Shortage Area Program (PSAP)-significantly increase the rural workforce, determining whether these programs continue to be successful is important. METHOD: The authors obtained, from the Jefferson Longitudinal Study, the 2007 practice location and specialty for the 2,394 PSAP and non-PSAP graduates of 11 previously unreported Jefferson graduating classes (1992-2002). They determined the relative likelihood both of PSAP versus non-PSAP graduates practicing rural family medicine and of all PSAP versus non-PSAP graduates practicing in Pennsylvania's rural counties. RESULTS: PSAP graduates were much more likely both to practice rural family medicine than their non-PSAP peers (32.0% [31/97] versus 3.2% [65/2,004]; relative risk [RR] = 9.9, confidence interval [CI] 6.8-14.4, P < .001) and to practice any specialty in rural Pennsylvania (PSAP 24.7% [24/97] versus non-PSAP 2.0% [40/2,004]; RR = 12.4, CI 7.8-19.7, P < .001). CONCLUSIONS: Despite major changes in health care in recent decades, Jefferson's PSAP continues to represent a successful model for substantially increasing the supply and distribution of rural family physicians. Especially with the forthcoming expansion in health insurance, access to care for rural residents will require an increased supply of providers. These results may also be important for medical schools planning to develop similar rural programs, given the new Rural Physician Training Grants program.