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Context: Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying provider types, practice locations, and practice productivity. Purpose: To identify mental health shortage areas using existing licensing and survey data. Methods: The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state--61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions. Findings: Notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000. Conclusions: States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

The term 'rural' suggests many things to many people, such as agricultural landscapes, isolation, small towns, and low population density. However, defining 'rural' for health policy and research purposes requires researchers and policy analysts to specify which aspects of rurality are most relevant to the topic at hand and then select an appropriate definition. Rural and urban taxonomies often do not discuss important demographic, cultural, and economic differences across rural places--differences that have major implications for policy and research. Factors such as geographic scale and region also must be considered. Several useful rural taxonomies are discussed and compared in this article. Careful attention to the definition of 'rural' is required for effectively targeting policy and research aimed at improving the health of rural Americans. doi:10.2105/AJPH.2004.042432)

Objective: Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians' screening practices. This study examines the association between physicians' nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines. Materials and Methods: A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence. Results: In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73–0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience. Conclusions: Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience. [ABSTRACT FROM AUTHOR]

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients. [ABSTRACT FROM AUTHOR]

Objectives: Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. Methods. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. Results. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a proportion of primary care physicians than urban private schools without family medicine departments. Conclusions. The values of American medical school and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes. [ABSTRACT FROM AUTHOR]

State action immunity from antitrust liability has been proposed as an important tool for preserving and strengthening fragile rural health care delivery systems. Washington is a leader in the use of state action immunity, having passed a statute and having approved several applications for immunity. This paper summarizes the current status of state action immunity, both in general and in Washington, including a review of the literature and an explication of issues of particular relevance to rural areas. Additionally, a summary is presented of inter-views with key informants in nine rural Washington communities, including an organization that had received a grant of immunity, one rural community just across a state border, and one other organization with rural operations that was given a grant of immunity. The interviews suggest that antitrust immunity, given the current interpretations of laws and guidelines by the courts, the Federal Trade Commission, and the Department of Justice, is not playing a significant role in the plans and decisions of health care providers in rural Washington. In larger rural areas, it was thought that activities could be structured to avoid antitrust liability without needing to apply for immunity; in smaller areas, there was little knowledge of antitrust issues, few resources to obtain knowledgeable advice, and little activity for which immunity might be useful. Overall, the authors did not find a large role for state action antitrust immunity in health care in rural Washington under current conditions. [ABSTRACT FROM AUTHOR]

Despite the prevalence of disabilities among persons living in rural areas, scarce data exist on their health care needs. While rural residents generally experience barriers to access to primary health care, these problems are further exacerbated for people with disabilities. This article summarizes findings from the published literature on access to primary health care among people with disabilities living in rural locations. A comprehensive computerized literature search turned up 86 articles meeting the study criteria, focused on the following rural populations affected by disabilities: children and adolescents, working-age adults, the elderly, the mentally ill, and people with AIDS. For each of these populations, substantial problems in accessing appropriate health care have been documented. The literature consistently emphasizes the failure of local health care systems in nonmetropolitan areas to adequately address the complex medical and related needs of individuals with disabilities. In the absence of specialized expertise, facilities, and primary care providers trained specifically to care for disabled persons, local programs rely heavily on the use of indigenous paraprofessionals and alternative models of care. Further research is needed to identify and test the efficacy of innovative service delivery strategies to improve health care access for this population. [ABSTRACT FROM AUTHOR]

Abstract: Objective. : To describe the primary surgical procedures and procedures for intraoperative and postoperative complications, and factors associated with these procedures, in women with ovarian cancer. Methods. : Using hospital discharge data from nine states, obtained from the Heath Care Cost and Utilization Project from 1999 to 2002, we evaluated 10,432 women with a primary diagnosis of ovarian cancer who underwent at least an oophorectomy for additional procedural ICD-9 codes during their initial hospitalization. Results. : Surgical procedures performed in addition to oophorectomy included: omentectomy/debulking 81.9%, hysterectomy 73.4%, lymph node dissection 41.4%, appendectomy 23.8%, bowel procedures 19.8%, laparoscopy 5.6%, diaphragmatic procedures 4.9%, colostomy 3.5%, and splenectomy 1.2%. Transfusions were given to 15.5% of patients. Intraoperative and postoperative procedures for complications were coded in 7.4% of patients, including repair of surgical injury 3.5%, procedures for cardiopulmonary complications 2.8%, reoperation 1.1%, and infection treatment 0.3%. In early stage disease 21.4% of women received no additional staging procedures and 46.8% did not have nodal sampling. In bivariate analysis of crude rates, factors associated with lymph node dissection were patient age, race, payer, teaching hospital status, hospital and surgeon volume, and surgeon specialty, p <.01. for all observations. Colostomies were performed by general surgeons in 23.1% of cases, by gynecologic oncologists in 2.7% of cases, and by obstetrician/gynecologists in no cases, p <.001. Complications were associated with age, payer, median household income, and stage, p <.001 for all observations. Complication rates were similar for low- and high-volume hospitals and surgeons. However, in higher volume settings, significantly more patients received debulking procedures, lymph node dissections, and additional surgical procedures, p <.001 for all observations. Conclusions. : A significant percentage of women with ovarian cancer did not receive recommended surgical procedures. Almost 50% of women with early stage disease were not adequately staged and in women with advanced disease, the percentage who had additional surgical procedures such as bowel resections was much lower than in institutions that report high optimal cytoreduction rates. [Copyright &y& Elsevier]