Change in Oregon maternity care workforce after malpractice premium subsidy implementation.

OBJECTIVES: (1) To determine the proportion of maternity care providers who continue to deliver babies in Oregon; (2) to determine the important factors relating to the decision to discontinue maternity care services; and (3) to examine how the rural liability subsidy is affecting rural maternity care providers' ability to provide maternity care services. STUDY DESIGN: We surveyed all obstetrical care providers in Oregon in 2002 and 2006. Survey data, supplemented with state administrative data, were analyzed for changes in provision of maternity care, reasons for stopping maternity care, and effect of the malpractice premium subsidy on practice. PRINCIPAL FINDINGS: Only 36.6% of responding clinicians qualified to deliver babies were actually providing maternity care in Oregon in 2006, significantly lower than the proportion (47.8%) found in 2002. Cost of malpractice premiums remains the most frequently cited reason for stopping maternity care, followed by lifestyle issues. Receipt of the malpractice subsidy was not associated with continuing any maternity services. CONCLUSIONS: Oregon continues to lose maternity care providers. A state program subsidizing the liability premiums of rural maternity care providers does not appear effective at keeping rural providers delivering babies. Other policies to encourage continuation of maternity care need to be considered.

Residency applicants' perspectives on family medicine residency training length.

BACKGROUND AND OBJECTIVES: The Future of Family Medicine report advocated experimentation with 4-year residency training models. This study examines residency applicants' opinions about extending the length of residency training and seeks to determine which features of an extended program would be most desirable to applicants. METHODS: We conducted a cross-sectional, descriptive, self-administered survey of residency applicant interviewees at Oregon's three family medicine residency training programs in 2004-2005. The survey included questions about demographics, factors influencing specialty choice, desirability of longer training programs, and desirability of certain types of additional training. RESULTS: A total of 155 surveys were returned, for an 89.1% response rate. Only 6% of respondents indicated that length of training was "very important" to their specialty choice; 85.0% indicated a preference for a 4-year program with or without specific experiences; 77.2% indicated that extended training would either increase their likelihood of choosing family medicine or would not affect their decision; and 79.3% indicated that a 4-year residency would not make them less likely to choose family medicine over other primary care specialties. Pregnancy care, trauma care, adolescent/child health, and procedural skills were the most commonly desired areas for additional training. CONCLUSIONS: Lengthening training to 4 years would have a neutral or positive effect on applicants' interest in family medicine training in Oregon.

Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Each year in the United States, 6000 to 7000 women with HIV give birth. The management and outcomes of prenatal HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996. PURPOSE: To synthesize current evidence on risks and benefits of prenatal screening for HIV infection. DATA SOURCES: MEDLINE, the Cochrane Library, reference lists, and experts. STUDY SELECTION: Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions. DATA EXTRACTION: Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force. DATA SYNTHESIS: No published studies directly link prenatal screening for HIV with clinical outcomes. In developed countries, the rate of mother-to-child transmission from untreated HIV-infected women is 14% to 25%. Targeted screening based on risk factors would miss a substantial proportion of infected women. "Opt-out" testing policies appear to increase uptake rates. Standard HIV testing is highly (>99%) sensitive and specific, and initial studies of rapid HIV tests found that both types of testing had similar accuracy. Rapid testing can facilitate timely interventions in persons testing positive. Recommended interventions (combination antiretroviral regimens, elective cesarean section in selected patients, and avoidance of breastfeeding) are associated with transmission rates of 1% to 2% and appear acceptable to pregnant women. LIMITATIONS: Long-term safety data for antiretroviral agents are not yet available. Data are insufficient to accurately estimate the benefits of screening on long-term maternal disease progression or other clinical outcomes, such as horizontal transmission. CONCLUSIONS: Identification and treatment of asymptomatic HIV infection in pregnant women can greatly decrease mother-to-child transmission rates.

Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: HIV infection affects 850,000 to 950,000 persons in the United States. The management and outcomes of HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996. PURPOSE: To synthesize the evidence on risks and benefits of screening for HIV infection. DATA SOURCES: MEDLINE, the Cochrane Library, reference lists, and experts. STUDY SELECTION: Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions. DATA EXTRACTION: Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force. DATA SYNTHESIS: No trials directly link screening for HIV with clinical outcomes. Many HIV-infected persons in the United States currently receive diagnosis at advanced stages of disease, and almost all will progress to AIDS if untreated. Screening based on risk factors could identify persons at substantially higher risk but would miss a substantial proportion of those infected. Screening tests for HIV are extremely (>99%) accurate. Acceptance rates for screening and use of recommended interventions vary widely. Highly active antiretroviral therapy (HAART) substantially reduces the risk for clinical progression or death in patients with immunologically advanced disease. Along with other adverse events, HAART is associated with an increased risk for cardiovascular complications, although absolute rates are low after 3 to 4 years. LIMITATIONS: Data are insufficient to estimate the effects of screening and interventions on transmission rates or in patients with less immunologically advanced disease. Long-term data on adverse events associated with HAART are not yet available. CONCLUSIONS: Benefits of HIV screening appear to outweigh harms. The yield from screening higher-prevalence populations would be substantially higher than that from screening the general population.

Factors influencing cessation of pregnancy care in Oregon.

BACKGROUND AND OBJECTIVES: Anecdotal evidence suggests that many providers who previously delivered babies are no longer doing so, both in Oregon and nationally. This study determined the proportion of pregnancy care providers who have stopped or are planning to stop providing this care in Oregon and identified the important factors influencing such practice changes. METHODS: We mailed a survey in October and November 2002 to all obstetrician-gynecologists, family physicians, general practitioners, and certified nurse midwives practicing in Oregon. The survey inquired about whether they currently perform deliveries. If they did not do so, or if they did so but planned to stop, further questions were asked about reasons for not providing this care. RESULTS: A total of 2,158 surveys were mailed; 1,232 were returned (58% adjusted response rate), and 1,069 had sufficient information to be included in our analysis. Of respondents, 511 (47.8%) currently perform deliveries. Of these, 157 (30.7%) indicated that they planned to stop doing so in 1 to 5 years, with cost of professional liability insurance (59%) and fear of lawsuits (43%) most frequently cited as major reasons. A total of 367 (34%) respondents had previously stopped performing deliveries. Providers who stopped providing this care since 1999 were significantly more likely to cite cost of medical liability insurance and low reimbursement as major reasons, compared to providers who stopped earlier. CONCLUSIONS: Our study suggests that as many as half of clinicians who previously performed or currently perform deliveries in Oregon are planning to stop or have already stopped providing this service, raising concern about access to pregnancy care services for women in the state.