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Biomedical subjects

K Grumbach

Publications and source records attributed to K Grumbach.

At least 55 records · Page 3Linked to original sources
PubMed1996

The role of black and Hispanic physicians in providing health care for underserved populations.

BACKGROUND: Patients who are members of minority groups may be more likely than others to consult physicians of the same race or ethnic group, but little is known about the relation between patients' race or ethnic group and the supply of physicians or the likelihood that minority-group physicians will care for poor or black and Hispanic patients. METHODS: We analyzed data on physicians' practice locations and the racial and ethnic makeup and socioeconomic status of communities in California in 1990. We also surveyed 718 primary care physicians from 51 California communities in 1993 to examine the relation between the physicians' race or ethnic group and the characteristics of the patients they served. RESULTS: Communities with high proportions of black and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Black physicians practiced in areas where the percentage of black residents was nearly five times as high, on average, as in areas where other physicians practiced. Hispanic physicians practiced in areas where the percentage of Hispanic residents was twice as high as in areas where other physicians practiced. After we controlled for the racial and ethnic makeup of the community, black physicians cared for significantly more black patients (absolute difference, 25 percentage points; P < 0.001) and Hispanic physicians for significantly more Hispanic patients (absolute difference, 21 percentage points; P < 0.001) than did other physicians. Black physicians cared for more patients covered by Medicaid (P = 0.001) and Hispanic physicians for more uninsured patients (P = 0.03) than did other physicians. CONCLUSIONS: Black and Hispanic physicians have a unique and important role in caring for poor, black, and Hispanic patients in California. Dismantling affirmative-action programs as is currently proposed, may threaten health care for both poor people and members of minority groups.

Black or African American↗
PubMed1996

Primary care and receipt of preventive services.

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services. DESIGN: A cross-sectional telephone survey. SETTING: Population based. PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California. INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication. MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p < .0001). Having health insurance (p < .001) and receiving optimal primary care from the regular place of care (p < .01) further significantly increased the likelihood of receiving preventive care services. CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care.

Adolescent↗
PubMed1996

Sonographic evaluation of acute pancreatic transplant rejection: morphology-Doppler analysis versus guided percutaneous biopsy.

OBJECTIVE: Despite the increasing success of pancreatic transplantation for diabetes, rejection remains the most common cause of graft loss. The purpose of this study was to correlate gray-scale sonographic morphology and Doppler resistive index (RI) with acute pancreatic transplant rejection as determined by percutaneous, sonographically guided biopsy of the pancreas. SUBJECTS AND METHODS: Fifty-one sonograms of 36 patients were correlated with sonographically guided biopsies performed for clinically suspected acute rejection. Sonographic studies consisted of gray-scale morphologic assessment of gland size, texture, marginal definition, peripancreatic fluid, and duct dilatation as well as measurement of the average Doppler RI. Biopsies were performed within 48 hr of sonography. After localization by sonography, we performed percutaneous biopsy with an 18-gauge automated biopsy device. RESULTS: Biopsy findings were acute rejection (n = 40, 78%), chronic rejection (n = 2, 4%), and no evidence of rejection (n = 9, 18%). Procedure-related hemorrhage occurred in one patient and resolved spontaneously. Gray-scale sonographic abnormalities were present in 37 studies (73%). The most common abnormality was pancreatic enlargement (n = 23) with a sensitivity and specificity of 58% and 100%, respectively, for acute rejection. Loss of marginal definition occurred in nine studies with a sensitivity and specificity of 15% and 73%, respectively, for acute rejection. An RI > or = 0.7 was found in 11 studies (22%) with a sensitivity of 20% and a specificity of 73% for acute rejection. CONCLUSION: For the diagnosis of acute pancreatic rejection, sonographically guided percutaneous biopsy is superior to gray-scale and spectral Doppler sonography. Sonographically guided percutaneous biopsy is a safe technique with a high success rate. Gray-scale and spectral Doppler sonography lack sensitivity, and a normal RI should not delay biopsy.

Acute Disease↗
PubMed1995

Regionalization of cardiac surgery in the United States and Canada. Geographic access, choice, and outcomes.

OBJECTIVE: To determine how regionalization of facilities for coronary artery bypass surgery (CABS) affects geographic access to CABS and surgical outcomes. DESIGN: Computerized hospital discharge records were used to measure hospital CABS volume and in-hospital post-CABS mortality rates. Relationships between surgical volume and age- and sex-adjusted mortality rates were compared using chi 2 tests. Small-area analysis of the association between CABS rates and distances to nearest CABS hospital was performed using multivariate linear regression methods. SETTING: All nonfederal hospitals in New York, California, Ontario, Manitoba, and British Columbia. PATIENTS: All adult residents of the five jurisdictions who underwent CABS in a hospital in their jurisdiction from 1987 through 1989. RESULTS: In New York and Canada, approximately 60% of all CABS operations took place in hospitals performing 500 or more CABS operations per year, compared with only 26% in California. The highest mortality rates were found among California hospitals performing fewer than 100 CABS operations per year (adjusted 14-day in-hospital mortality was 4.7% compared with 2.4% in high-volume California hospitals, P < .001). The percentage of the population residing within 25 miles of a CABS hospital was 91% in California, 82% in New York, and less than 60% in Canada. Eliminating very low-volume (< 100 cases per year) CABS hospitals in California would increase travel distances to a CABS hospital only slightly for a small number of residents. The Canadian degree of regionalization was not associated with lower CABS rates within provinces for populations living at more remote distances from the nearest CABS hospital. CONCLUSION: Regionalization of CABS facilities in New York and Canada largely avoids the problem of low-volume outlier hospitals with high postoperative mortality rates found in California. New York has avoided the redundancy of facilities that exists in California while still providing residents a geographically convenient selection of CABS hospitals. Stricter regionalization in Canada may leave residents with a more narrow choice of facilities, but does not disproportionately affect access to surgery for populations living at remote distances from CABS facilities.

Canada↗
PubMed1995

Hospitalization for congestive heart failure. Explaining racial differences.

OBJECTIVE: To determine whether the higher rate of hospitalization among African Americans for congestive heart failure (CHF) could be explained by racial differences in the prevalence of clinical risk factors for CHF. DESIGN: Retrospective cohort study. SETTING: A large health maintenance organization (HMO). PATIENTS: A sample of 64,877 enrollees (27% African American and 73% white) of the Northern California Kaiser Permanente Medical Care Program who took at least one multiphasic health checkup (MHC) at or after the age of 40 years and were free of CHF at that time. MAIN OUTCOME MEASURES: First hospitalization with a principal diagnosis of CHF. RESULTS: Among cohort members younger than 60 years at baseline MHC, the age-adjusted risk ratio (RR) (African American/white) for CHF hospitalization was 2.14 for men and 2.73 for women, while for persons 60 years of age and older at MHC, the age-adjusted RR was 1.48 for both sexes. Cox proportional hazards models were used to adjust for risk factors and length of follow-up. In persons aged 60 years and older, the race difference was explained by greater prevalence of hypertension and diabetes in African Americans (RR = 1.12; 95% confidence interval [CI], 0.94 to 1.34 after adjustment for hypertension and diabetes). In those younger than 60 years, findings differed by sex. For men, African-American race was no longer a significant predictor of CHF after adjusting for hypertension, diabetes, left ventricular hypertrophy on electrocardiogram, and body mass index (adjusted RR = 1.16; 95% CI, 0.86 to 1.56). However, among younger women, African Americans continued at increased risk despite adjustment for these variables as well as smoking, plasma cholesterol, renal function, alcohol use, and myocardial infarction (adjusted RR = 1.49; 95% CI, 1.00 to 2.21). CONCLUSIONS: In this HMO population, the race differences in first hospitalization for CHF are largely explained by known clinical and behavioral risk factors, although in younger women these risk factors do not completely explain the excess risk among African Americans. These findings highlight the role of hypertension and diabetes in the development of CHF, particularly among African Americans.

Black People↗
PubMed1995

Graduate medical education and physician practice location. Implications for physician workforce policy.

OBJECTIVE: To determine the relationship between graduate medical education and physician practice location. DESIGN: Cross-sectional analysis of physicians in active practice in 1993, classified by state of graduate medical education and stratified by specialty and professional activity. Logistic regression analysis was used to examine predictors of physicians remaining to practice in the same state in which they trained. SETTING: There were 82,871 allopathic physicians (national random sample) and 15,076 osteopathic physicians (universe) who completed graduate medical education between 1980 and 1992. MAIN OUTCOME MEASURE: Practice location in the same state as graduate medical education. RESULTS: Overall, 51% of physicians are practicing in the state in which they obtained their graduate medical education (range among states, 6% to 71%). Generalist physicians are more likely than specialists to remain in their state of graduate medical education (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.33 to 1.40) There is a weak negative association between the number of physicians in training per capita in a state and the likelihood of a physician remaining in the state to practice (OR, 0.90; 95% CI, 0.90 to 0.91, for an increment in resident supply of 10 per 100,000 population). New York and Massachusetts, the states with the highest numbers of residents per capita, retained 51% and 49%, respectively, of their graduates, placing them near the median among states. CONCLUSIONS: Most physician training and practice locations function as a national market, with physicians dispersing relatively widely after completing graduate medical education. States that produce high numbers of physicians per capita do not appear to play a unique role in training physicians to serve a national market. These findings pose challenges for states attempting to modify their physician supply and specialty mix.

Cross-Sectional Studies↗
PubMed1995

Preventable hospitalizations and access to health care.

OBJECTIVE: To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style. DESIGN: Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas. SETTING: Community based. PARTICIPANTS: A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities. MAIN OUTCOME MEASURES: We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style. RESULTS: Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R2 = 0.50; P < .001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P < .002) and the prevalence of the conditions (P < .03) remained independent predictors. CONCLUSION: Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.

Adult↗
PubMed1995

The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data.

OBJECTIVES: The study reviewed methods for measuring the specialty distribution of the US physician workforce. It was hypothesized that current databases and measurement conventions overestimate the number of generalist physicians. METHODS: A descriptive analysis of the American Medical Association (AMA) Physician Masterfile for California was done with different assumptions about the definition of generalists based on primary and secondary specialty information. RESULTS: A rigorous definition of generalist physician that excludes physicians with secondary practices in specialist fields resulted in an estimate of generalist physicians 25% lower than the number estimated by conventional workforce evaluation methods. Physicians who reported practicing in both generalist and specialist fields were more likely to be older, to be international medical school graduates, and to be in solo or duo practice compared with physicians who listed only generalist or specialist fields. CONCLUSIONS: The actual number of generalist physicians in the United States may be less than previously believed. Although the exact magnitude of the "hidden system" of specialists providing primary care is difficult to measure, at least a portion appear to already be counted as generalist physicians by current conventions.

American Medical Association↗
PubMed1994

Refusing care to emergency department of patients: evaluation of published triage guidelines.

STUDY OBJECTIVE: To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care. DESIGN: Historical cohort study. SETTING: A public hospital ED. TYPE OF PARTICIPANTS: All patients triaged during a one-week period who were not in the most acute triage category. MEASUREMENTS: Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome. MAIN RESULTS: Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized. CONCLUSION: When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Adult↗