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Little is known about the potential of nurse practitioner (NP) residency and fellowship programs in preparing NPs for the future of the health care system. We describe NP residency and fellowship programs in terms of their number and general characteristics. We found nearly 70 residency and fellowship programs across the country. The programs are geographically dispersed and diverse in terms of the specialty area, type of organization overseeing the program, and program length. Our study is the first to describe these programs, but a more in-depth investigation is necessary to understand the role that these programs can play in the future.

Objectives: Vaccine hesitancy among essential workers remains a significant public health challenge. We examined psychological constructs of perceived susceptibility, threat, and self-efficacy and their associations with COVID-19 vaccine hesitancy among a racially and ethnically diverse essential workforce population.Methods: We performed a cross-sectional survey of essential workers from September-December 2020 at a large Los Angeles safety-net medical center as part of a program offering free COVID-19 serology testing. Program participants completed a standardized survey at the time of phlebotomy. Hierarchical logistic regression was utilized to determine factors independently associated with vaccine hesitancy.Results: Among 1327 persons who had serology testing, 1235 (93%) completed the survey. Of these, 958 (78%) were healthcare workers. Based on expressed intent, 22% were vaccine-hesitant 78% were vaccine acceptors. In our multivariate model, vaccine hesitancy was associated with female gender [aOR = 2.09; 95% CI (1.44-3.05)], African American race [aOR = 4.32; (2.16-8.62)], LatinX ethnicity [aOR = 2.47; 95% CI (1.51-4.05)] and history of not/sometimes receiving influenza vaccination [aOR = 4.39; 95% CI (2.98-6.48)]. Compared to nurses, vaccine hesitancy was lower among physicians [aOR = 0.09; 95% CI (0.04-0.23)], non-nursing/non-physician healthcare workers [aOR = 0.55; 95% CI (0.33-0.92)], and non-healthcare care workers [aOR = 0.53; 95% CI (0.36-0.78)].Conclusions: Among a racially/ethnically diverse group of safety net medical center essential workers, COVID-19 vaccine hesitancy was associated with racial/ethnic minority groups, employment type, and prior influenza vaccination hesitancy. Interestingly, we found no association with the Health Belief Model construct measures of perceived susceptibility, threat, and self-efficacy. Psychological constructs not assessed may be drivers of vaccine hesitancy in our population.

Wide variations exist in healthcare expenditures, though most prior studies have assessed aggregate utilization. We sought to examine healthcare utilization variation in New York State by assessing hospitals in peer groups of similar capabilities.

Managed care may improve access to health care to previously underserved populations when providers need plan enrollees. However, capitation and utilization management often give providers the incentive to withhold care. Managed care organizations have yet to demonstrate that racial disparities in treatment are not exacerbated. Using Medicaid eligibility, claims, and managed care encounter data, we examine racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care. We use count data models adjusted for nonrandom selection within difference-in-differences econometric approaches. The results show that mandatory enrollment has disproportionately reduced the relative use of physician and inpatient services among African-American beneficiaries.

We examined the differential effect of Medicaid managed care (MMC) among Aid to Families With Dependent Children (AFDC) and Supplemental Security Income (SSI) enrollees over time by comparing the experiences of adult nonelderly enrollees in the Health Plan of San Mateo in California versus Ventura County’s fee-for-service (FFS) enrollees.

Explanations for regional variation in the use of many medical and surgical treatments is controversial.

• A review of 386 Medicare patients with hip fractures admitted to a private, suburban, teaching hospital from 1981 through 1987 revealed that since the implementation of the prospective payment system in 1984, average hospital stays declined from 17.0 days to 12.9 days (24.1%). Although the mean number of physical therapy sessions declined from 11.1 to 9.8 (11.7%), the average number of treatments per day during the physical therapy phase actually increased from 1.2 before to 1.4 after the prospective payment system. The proportion of patients discharged to nursing homes remained the same (52.9% vs 53.6%); the proportion of patients remaining in a nursing home 6 months after hospital discharge did not differ significantly (22.6% vs 19.9%). Furthermore, there were no differences in the 6-month ambulation status. Total adjusted average hospital charges for the pre–and post–prospective payment system groups did not increase significantly ($7295 vs $7565). These findings do not support the contention that the quality of care provided Medicare patients with hip fractures has deteriorated in this hospital environment.(Arch Intern Med. 1989;149:2237-2241)

Individual Practice Associations (IPAs) must be able to recruit physicians from the community to compete in the future. This article reports the results of a study to assess the factors that influenced physicians in the Research Triangle area of North Carolina to join a primary care network type of IPA. Results indicate that physicians with lower incomes and fewer physician visits and those who were newly established in the community were more likely to join. Peers had a strong influence on their decisions, while Blue CrossBlue Shield marketing representatives did not.

This article presents a typology for use in classifying and interpreting the findings of the growing empirical literature on managed care initiatives in the Medicaid program. Six key program attributes are identified for use in examining similarities and differences among these programs. Several alternative arrangements for each attribute are described from among the more than 60 different programs attempted. The typology is illustrated with five specific program designs, and selected empirical results from them are used to demonstrate how the typology can be employed.

Economic analyses have become increasingly important in healthcare in general and with respect to pharmaceuticals in particular. If economic analyses are to play an important and useful role in the allocation of scarce healthcare resources, then such analyses must be performed properly and with care. This article outlines some of the basic principles of pharmacoeconomic analysis. Every analysis should have an explicitly stated perspective, which, unless otherwise justified, should be a societal perspective. Cost minimisation, cost-effectiveness, cost-utility and cost-benefit analyses are a family of techniques used in economic analyses. Cost minimisation analysis is appropriate when alternative therapies have identical outcomes, but differ in costs. Cost-effectiveness analysis is appropriate when alternative therapies differ in clinical effectiveness but can be examined from the same dimension of health outcome. Cost-utility analysis can be used when alternative therapies may be examined using multiple dimensions of health outcome, such as morbidity and mortality. Cost-benefit analysis requires the benefits of therapy to be described in monetary units and is not usually the technique of choice. The technique used in an analysis should be described and explicitly defended according to the problem being examined. For each technique, the method of determining costs is the same; direct, indirect, and intangible costs can be considered. The specific costs to be used depend on the analytical perspective; a societal perspective implies the use of both direct and indirect economic costs. A modelling framework such as a decision tree, influence diagram, Markov chain, or network simulation must be used to structure the analysis explicitly. Regardless of the choice of framework, all modelling assumptions should be described. The mechanism of data collection for model inputs must be detailed and defended. Models must undergo careful verification and validation procedures. Following baseline analysis of the model, further analyses should examine the role of uncertainty in model assumptions and data.

An emerging issue in health care is the relative efficiency with which local health departments provide their services. The problem is complicated by the fact that many factors may contribute to variations in efficiency. We have developed a framework for analyzing such variations across departments, using cost per service (CPS) as the measure of efficiency. The approach is illustrated with data from all 82 county or district health departments in North Carolina. CPS levels can be differentially affected by selected uncontrollable characteristics of the serviced population. Thus, when used to evaluate departmental performance, or to determine reimbursement rates, the CPS must be adjusted for relevant exogenous factors. Our method of cluster analysis accounts “naturally” for these factors, thereby allowing for development of policy decisions more responsive to actual health department circumstances.

The authors investigated possible differences between specialists and generalists in the intensity with which they treat patients with asthma by studying the care of 283 patients between the ages of six and 40 provided by 13 allergists and 40 randomly selected physicians in two primary care specialties pediatrics and family practice. After excluding patients with more than one physician, allergists' patients were nearly identical to primary care physicians' patients in the frequency and duration of symptoms, and they had a similar number of asthma-related emergency room visits in the previous year and asthma-related hospitalizations in the preceding 3 years. The allergists treated their patients significantly more intensively than did the primary care physicians. Sixty-two percent of allergists' patients had received oral corticosteroids in the preceding year compared with 30 of primary care patients (P<0.001). More of the allergists' patients had received oral corticosteroids throughout the year (9 vs. 0, respectively, P<0.01). They were also more likely to have used corticosteroid inhalers (46 vs. 19) and a greater number of asthma medications (mean2.8 vs. 1.3). In a separate survey of the same physicians, using clinical vignettes, the allergists were more likely to prescribe corticosteroid tablets and inhalers. These findings suggest that specialists and generalists differ in the intensity with which they treat patients with asthma and cannot be explained by patient selection or severity differences.

Each year approximately 100,000 Medicare patients undergo knee replacement surgery. Patients, referring physicians, and surgeons must consider a variety of factors when deciding if knee replacement is indicated. One factor in this decision process is the likelihood of revision knee replacement after the initial surgery. This study determined the chance that a revision knee replacement will occur and which factors were associated with revision.

The documented growing morbidity, mortality, and disability from asthma indicate a failure in effective delivery of appropriate care. This article reviews how different components of organizational technology in hospitals, freestanding emergency centers, physician practices, prepaid groups, and schools may be linked to asthma care and asthma outcomes. A framework to address how practice patterns, risk factors, and outcomes relate to organizational characteristics, such as time orientation, uncertainty, available technology, standardization of work, specialization of work, coordination, and control strategies, is presented.

ABSTRACTGene therapy research has the potential to revolutionize the way in which many human diseases are treated. Despite its enormous potential, roundtable panelists concluded that the field needs time to mature scientifically without pressure to develop a marketable therapeutic product. In addition, health care decision makers, physicians, and the lay public need to be educated on the future medical, economic, and ethical ramifications of gene therapy.

Highway freight and passenger transportation are vital contributors to national economic health and productivity. Although there has been considerable research into the design and operation of the highway system and the vehicles that use it, there has been relatively little concentrated research concerning the truck and bus driver – the human element responsible for moving the freight and passengers safely.The Federal Highway Administration's Office of Motor Carriers has developed a comprehensive multi-year plan to address the issues of driver proficiency, medical qualifications, and fitness for duty. The core of this plan will be a series of high-quality and scientifically sound research projects. The results of these projects will form the basis for regulatory changes that will be more technically defensible, better reflect the realities of the operating environments, and, to the extent possible, be based on performance standards.

This paper describes how the PORTS are using data from the Medicare administrative records systems to study the medical care costs of specific conditions. The general strengths and weaknesses of the Medicare databases for studying cost related issues are discussed, and the relevant data elements are examined in detail. Changes in the nature of the data collected over time are noted. Information is provided on how the PORTS are using these data to estimate the cost to Medicare of treating Medicare beneficiaries with specific conditions and the social (opportunity) cost of treating these patients. Furthermore, information is provided on how data from the Medicare administrative records system can be used to determine the cost of services for patients who have been identified through other large databases (i.e., state hospital discharge tapes) or who have been enrolled in prospective cohort studies.

The heavy vehicle industry includes medium-duty trucks, heavy-duty trucks, and buses. Vehicle size, driver location relative to the road, and duration of time in the vehicle distinguish heavy vehicles from the passenger car and light truck industry. During the past decade, the industry has been changing. Technological advances, as well as political, economic, and cultural forces, have combined to create a new environment. The driver has become more important in this new environment. A driver shortage and safety issues have heightened the interest in human factors and ergonomics in the heavy vehicle industry.The purpose of this symposium is to highlight some of the current human factors research in the field of heavy vehicles. While there are many possible topics to discuss, the first two papers will address vehicle design issues and the second two papers will address operational issues.Ms. Kinghorn will discuss a technique to estimate the current population of US Truck Drivers. She proposes that some of the shortcomings of the available data, such as changes in the population over the last decade and dimensions for which no data are available, can be overcome by estimating the current truck driver population from data on the general population.Mr. Reynolds will discuss the discrepancies observed between a design eyellipse location and actual driver eye locations in a small exploratory study. He will describe the primary contributor to the discrepancy, the H-point, and suggest several other potential contributors.Ms. Feyer will discuss a study on the effects of operational practices on driver fatigue. She will compare and contrast the operational practices of various segments of the long distance passenger and freight hauling industries. Her results indicate that different strategies must be applied to the passenger and freight industries to combat fatigue, even though the causes of fatigue are the same.Ms. Freund is from the US Federal Highway Administration's Office of Motor Carriers. She will discuss their plans for research concerning truck and bus driver operational regulation. Specific areas that are of interest include proficiency testing, fitness for duty, and substance abuse. She will elaborate on the program, addressing driver fatigue and loss of alertness.