Increased rates and severity of child and adult food insecurity in households with adult smokers.

OBJECTIVE: To investigate rates and severity of child and adult food insecurity (the inability to access enough food in a socially acceptable way for every day of the year) in households with and without smokers. DESIGN: Cross-sectional survey. SETTING: Nationally representative sample of the US population from 1999 to 2002. PARTICIPANTS: Households with children through age 17 years (n = 8817) in the National Health and Nutrition Examination Survey. Main Exposure Presence or absence of adult smokers in the household. Covariates included age, sex, and race/ethnicity of the child, and the poverty index ratio. Main Outcome Measure Rates and severity of food insecurity were ascertained using the US Department of Agriculture Food Security Survey Module. RESULTS: Food insecurity was more common and severe in children and adults in households with smokers. Of children in households with smokers, 17.0% were food insecure vs 8.7% in households without smokers (P < .001). Rates of severe child food insecurity were 3.2% vs 0.9% (P < .04), respectively. For adults, 25.7% in households with smokers and 11.6% in households without smokers were food insecure, and rates of severe food insecurity were 11.8% and 3.9%, respectively (P < .003 for each). Food insecurity was higher in low-income compared with higher income homes (P < .01). At multivariate analyses, smoking was independently associated with food insecurity and severe food insecurity in children (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.7, and adjusted odds ratio, 3.1; 95% confidence interval, 1.4-6.9, respectively) and adults (adjusted odds ratio, 2.2; 95% confidence interval, 1.6-3.0, and adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.7, respectively). CONCLUSIONS: Living with adult smokers is an independent risk factor for adult and child food insecurity, associated with an approximate doubling of its rate and tripling of the rate of severe food insecurity.

Changing policies on vaginal birth after cesarean: impact on access.

BACKGROUND: The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be "immediately available" for women in labor attempting VBAC. METHODS: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued. RESULTS: Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001). CONCLUSIONS: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.

Medical student attitudes to risk taking and self-perceived influence on medical practice.

CONTEXT: Little has been published on medical student risk-taking attitudes and behaviours and whether students think these attributes will affect how they treat patients. OBJECTIVES: Our aims were to assess for an association between risk-taking attitudes and behaviours, such as problematic substance use, self-reported risky behaviours, and self-reported accidents, and to test for an association between risk-taking attitudes and student perceptions of the influence of these attitudes on future clinical practice. METHODS: Three consecutive classes of Year 2 medical students (n=315) completed a self-administered, 29-item questionnaire. Risk-taking attitudes were evaluated using a 6-question, risk-taking scale adapted from the Jackson Personality Inventory (JPI). RESULTS: A significant positive correlation was demonstrated between risk-taking attitudes (JPI) and problematic substance use (r=0.34; P<0.01), self-reported risky behaviours (r=0.47; P<0.01), and self-reported accidents (r=0.33; P<0.01). Students who did not think their attitudes toward risk would affect their clinical decision making scored significantly higher on our measure of risk-taking attitudes (t306=-4.60; P<0.01). Students who did not think that their drinking, drug taking or sexual behaviour would affect how they counselled patients on these matters scored significantly higher on our measure of problematic substance use (t307=-2.51; P=0.01). CONCLUSIONS: Although risk-taking attitudes have been associated with significant differences in clinical decision making among doctors, in our sample students with high risk-taking attitudes and behaviours were significantly less likely than their colleagues to think their attitudes would affect their clinical practice. Implications for medical education are discussed.

Specialist physicians providing primary care services in Colorado.

BACKGROUND: There is general consensus that the size of the US physician workforce now exceeds the health care needs of the American public. There is a greater proportion of specialists than primary care physicians, a specialty mix different from that of most other developed countries. METHODS: The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: "How many hours in the last week did you provide primary care services, defined as either preventive care, routine physical exams, or treatment of common ailments?" The responses of physicians who reported non-primary-care medical specialties were analyzed with respect to their personal and practice characteristics. RESULTS: Just under half (46.5%) of the 2745 specialist respondents reported having provided primary care services. As a group, however, 27.9% of specialist physicians' direct patient care time was devoted to primary care activities. The amount of primary care services being provided was greater among those not board-certified in their specialties, osteopathic physicians, and specialists spending less time in direct patient care. CONCLUSION: Additional evaluation is needed with a more comprehensive definition of primary care than used in this article, which includes important but difficult-to-measure elements, such as the integration of services, a sustained partnership with patients, and practice in the context of family and community. To the extent possible, this definition should not rely on physician self-definition of which examinations are routine and which ailments are common. However, the contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services.

The Balanced Budget Act of 1997 and the financial health of teaching hospitals.

BACKGROUND: We wanted to evaluate the most recent, complete data related to the specific effects of the Balanced Budget Act of 1997 relative to the overall financial health of teaching hospitals. We also define cost report variables and calculations necessary for continued impact monitoring. METHODS: We undertook a descriptive analysis of hospital cost report variables for 1996, 1998, and 1999, using simple calculations of total, Medicare, prospective payment system, graduate medical education (GME), and bad debt margins, as well as the proportion with negative total operating margins. RESULTS: Nearly 35% of teaching hospitals had negative operating margins in 1999. Teaching hospital total margins fell by nearly 50% between 1996 and 1999, while Medicare margins remained relatively stable. GME margins have fallen by nearly 24%, however, even as reported education costs have risen by nearly 12%. Medicare + Choice GME payments were less than 10% of those projected. CONCLUSIONS: Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. Medicare payments remain an important financial cushion for teaching hospitals, more than one third of which operated in the red. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate. Medicare + Choice support of the medical education enterprise is 90% less than baseline projections and should be thoroughly investigated. The Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes, should be more transparent in its methods.

The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location.

BACKGROUND: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location. METHODS: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location. RESULTS: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated. CONCLUSIONS: Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.