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Biomedical subjects

Larry A Green

Publications and source records attributed to Larry A Green.

At least 37 records · Page 2Linked to original sources
PubMed2002

Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care?

OBJECTIVES: A usual source of care is associated with better health outcomes. Dissatisfaction among family physicians and general practitioners (FP/GPs) may compromise the accessibility of a usual source of care and the quality of services. We examined the association between FP/GP dissatisfaction and an inability to deliver high-quality care. STUDY DESIGN: We performed a secondary data analysis of the Community Tracking Study (CTS) Physician Survey (1996-1997). POPULATION: The study included a nationally representative sample of more than 12,000 nonfederal physicians practicing direct patient care in the United States. OUTCOMES MEASURED: We measured associations of career dissatisfaction with physicians&amprsquo perceptions of their ability to provide high-quality care as defined by 6 survey items. Multivariate analyses controlled for the effects of personal, professional, and practice characteristics. RESULTS: Among FP/GPs in 1996-1997, more than 17% were dissatisfied. Age was the most significant personal factor associated with dissatisfaction; 25.1% of those aged 55 to 64 years reported dissatisfaction compared with only 10.1% of those younger than 35 years. Other personal or professional characteristics significantly associated with FP/GP dissatisfaction included osteopathic training, graduation from a foreign medical school, full practice ownership, and an income of less than $100,000. Physicians dissatisfied with their careers were much more likely to report difficulties in caring for patients, strongly disagreeing (vs strongly agreeing, odds ratio [OR] 1.0) that they had enough clinical freedom (OR 7.89; 95% confidence interval [CI], 4.86-12.83); continuous patient relationships (OR 7.11; 95% CI, 4.90-10.33); no financial penalties for clinical decisions (OR 4.44; 95% CI, 3.13-6.31); adequate time with patients (OR 4.42; 95% CI, 2.84-6.87); ability to provide quality care (OR 4.26; 95% CI, 2.88-6.31); and sufficient communication with specialists (OR 3.57; CI, 2.20-5.80). CONCLUSIONS: An inability to care for patients is significantly associated with career dissatisfaction. This relationship has implications for the achievement of policy objectives related to access, having a usual source of care, and quality.

Adult↗
PubMed2002

The increase in international medical graduates in family practice residency programs.

BACKGROUND AND OBJECTIVES: The number of filled positions in family practice residency programs decreased by 18.6% from 1997-2001. This study sought to determine the degree of reliance on international medical graduates (IMGs) to fill family practice residency positions and the relative proportion of US citizen IMGs. METHODS: We analyzed the 1992-2001 National Resident Matching Program results, the 2000 American Medical Association Masterfile, and the 1992-2001 American Academy of Family Physicians Annual Survey of Family Practice Residency Programs. RESULTS: The percentage of IMGs matching in family practice remained stable between the years of 1992-1996 (10.0%-11.8%) but since 1997 has increased to a high of 21.4% in 2001. This rise in IMGs corresponds with a drop in the total percentage of family practice residency positions filled in the Match from 90.5% in 1996 to 76.3% in 2001. Despite the drop in Match numbers, the percentage of first-year family practice positions filled in July has remained in the range of 95.5%-97.8% since 1996. IMGs account for an increasing percentage of post-Match fills from 16.7% in 1996 to 47.9% in 2001. In 1999, a majority of family practice programs (279 [55.6%]), had at least one IMG. Of these, 48 programs (9.6%) had at least 50% of residents who were IMGs, and eight programs (1.6%) were entirely composed of IMGs. In five states (Connecticut, Illinois, Michigan, New Jersey, and New York), more than 25% of family practice residents were IMGs. CONCLUSIONS: Family practice is becoming increasingly reliant on IMGs to fill residency positions.

Career Mobility↗
PubMed2002

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.

Career Choice↗
PubMedDate not supplied

The Future of Family Medicine: a collaborative project of the family medicine community.

BACKGROUND: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Ambulatory Care Information Systems↗
PubMedDate not supplied

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.

Budgets↗
PubMedDate not supplied

Opportunities, challenges, and lessons of international research in practice-based research networks: the case of an international study of acute otitis media.

The requirements of research become more complex and demanding in international collaborations. The opportunity to study naturally occurring variation in treatment prompted networking primary care research networks in the United Kingdom, The Netherlands, and North America to study acute otitis media. Additional challenges faced and addressed in this study included (1) differing national requirements for protecting human subjects; (2) variation in data collection processes in primary care practices; (3) data transmission among participants; (4) duties and tariffs on necessary instruments; (5) fluctuation in currency exchange rates; (6) incapacitation of coinvestigators; (7) complex administration of funds; (8) financing the additional, legitimate costs of collaboration; (9) sustaining strong personal relationships among coinvestigators; and (10) accepting longer time frames than would otherwise be expected. Overall, international practice-based research can be productive, affect millions of people, and be extremely rewarding to investigators. It is not, however, for the faint-hearted.

Adolescent↗
PubMedDate not supplied

Practical and relevant self-report measures of patient health behaviors for primary care research.

PURPOSE: With increasing evidence for the value of behavior change counseling, there is a need for health behavior measurements that can be implemented in primary care research. This article discusses criteria for and reviews self-report measures to briefly assess cigarette smoking, eating patterns, physical activity, and risky drinking across the life course. It then proposes pragmatic measures for use in practice-based research. METHODS: Drawing from literature reviews, previous multisite studies, personal communications with experts in the field, and guidance from an expert panel, we identified self-report behavior change measures and gave priority to items that addressed Healthy People 2010 goals, as well as those that were practical (ie, shorter, and easier to score and use for intervention), were sensitive to change, and produced results that could directly inform primary care intervention. RESULTS: Separate recommendations are described for measures for adults and for children/adolescents. We recommend a set of 22 items for adults and 16 items for adolescents to track succinctly their status on the 4 health behaviors above. Perfected measures remain elusive: newly developed measures of physical activity and eating patterns are recommended, and in general, the brief measures for adults are currently better validated than are the child measures. CONCLUSIONS: A set of totally satisfactory practical instruments for measuring behavior change in primary care settings does not yet exist. There is sufficient progress to encourage use of and further research on the proposed items. Use of a common set of items across different interventions and projects will help to advance clinical and behavioral research in primary care settings.

Adolescent↗
PubMedDate not supplied

COGME's 16th Report to Congress: too many physicians could be worse than wasted.

Departing from past reports, the latest Council on Graduate Medical Education (COGME) report warns of a physician deficit of 85,000 by 2020 and recommends increases in medical school and residency output. COGME notes that contributions of other clinicians and changes in how medical care is delivered in the future would likely offset physician deficits but chose not to modify their recommendations. COGME offers a relatively minor workforce correction in an otherwise flawed system of health care; however, the nation awaits a reassessment of its physician workforce based on what the nation wants and needs from physicians working in modern systems of care. Great caution should be exercised in expanding the physician workforce. Producing a physician surplus could be far worse than wasted, because the investment required and resulting rise in health care cost may harm, not help, the health of people in the United States. Instead, these resources could be applied in ways that improve health.

Health Workforce↗
PubMedDate not supplied

Prescription for health: changing primary care practice to foster healthy behaviors.

PURPOSE: The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices. METHODS: Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons. RESULTS: PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities. CONCLUSIONS: These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Health Behavior↗
PubMedDate not supplied

Variation in the ecology of medical care.

BACKGROUND: We wanted to quantify how the location in which medical care is delivered in the United States varies with the sociodemographic characteristics and health care arrangements of the individual person. METHODS: Data from the 1996 Medical Expenditures Panel Survey (MEPS) were used to estimate the number of persons per 1,000 per month in 1996 who had at least 1 contact with physicians' offices, hospital outpatient departments, or emergency departments, hospitals, or home care. These data were stratified by age, sex, race, ethnicity, household income, education of head of household, residence in or out of metropolitan statistical areas, having health insurance, and having a usual source of care. RESULTS: Physicians' offices were overwhelmingly the most common site of health care for all subgroups studied. Lacking a usual source of care was the only variable independently associated with a decreased likelihood of care in all 5 settings, and lack of insurance was associated with lower rates of care in all settings but emergency departments. Generally, more complicated patterns emerged for most sociodemographic characteristics. The combination of having a usual source of care and health insurance was especially related to higher rates of care in all settings except the emergency department. CONCLUSION: Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care.

Adolescent↗
PubMedDate not supplied

The US Medical Liability System: evidence for legislative reform.

BACKGROUND: Despite state and federal efforts to implement medical malpractice reform, there is limited evidence on which to base policy decisions. The National Practitioner Data Bank (NPDB) offers an opportunity to evaluate the effects of previous malpractice tort reforms on malpractice payments and premiums. METHODS: For every state and the District of Columbia, we calculated the number of malpractice payments, total amount paid, and average payment from NPDB data reported from 1999 through 2001. We analyzed 44,913 claims using logistic regression to study associations between payments, physician premiums, and 10 state statutory tort reforms. RESULTS: Wide variations exist in malpractice payments among states. The reforms most associated with lower payments and premiums were total and noneconomic damage caps. Mean payments were 26% lower in states with total damage caps (196,495.34 dollars vs 265,554.50 dollars, P = .001). Mean payments were 22% less in states with noneconomic damage caps (219,225.98 dollars vs 279,849.86 dollars, P = .010). Total damage caps were associated with lower mean annual premiums, especially for obstetricians (22,371.57 dollars vs 42,728.68 dollars, P <.001). Hard noneconomic damage caps were associated with premium reductions for obstetricians (30,283.75 vs 45,740.88; P = .039). CONCLUSIONS: Significant reductions in malpractice payments could be realized if total or noneconomic damage caps were operating nationally. Hard noneconomic damage and total damage caps could yield lower premiums. If tied to a comprehensive plan for reform, the money saved could be diverted to implement alternative approaches to patient compensation or be used to achieve other systems reform benefiting patients, employers, physicians, and hospitals.

Cost Control↗
PubMedDate not supplied

Can nurse practitioners and physicians beat parochialism into plowshares?

Nurse practitioners have evolved into a large and flexible workforce. Far too often, nurse practitioner and physician professional organizations do not work together but rather expend considerable effort jousting in policy arenas. Turf battles interfere with joint advocacy for needed health system change and delay development of interdisciplinary teams that could help patients. A combined, consistent effort is urgently needed for studying, training, and deploying a collaborative, integrated workforce aimed at improving the health care system of tomorrow. The country can ill afford doctors and nurses who ignore one another's capabilities and fail to maximize each other's contributions cost-effectively.

Certification↗
PubMedDate not supplied

Adding more specialists is not likely to improve population health: is anybody listening?

Before a shortage of physicians, and particularly subspecialists, in the United States is declared, it is worth reviewing the considerable evidence that calls into question whether further specialization automatically improves health. Barbara Starfield and colleagues' latest research reveals, again, that having more specialists may not be a good thing. The current workforce functions well as an economic engine, but continued emphasis on market demand will likely widen disparities in workforce distribution and population health. The resurgence of interest in shaping the future physician workforce should lead to purposeful choices about what we want them to do and the outcomes we expect.

Health Status↗
PubMedDate not supplied

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.

Adult↗
PubMedDate not supplied

Follow-up on family practice residents' perspectives on length and content of training.

BACKGROUND: The structure of family practice residency programs remains essentially unchanged from the model first proposed more than 35 years ago. Advances in medical technology and knowledge combined with increasing restrictions on resident work hours and decreasing medical student interest invite reconsideration of how family physicians are trained. METHODS: We resurveyed 442 third-year family practice residents who had participated in a prior study in 2000 to determine whether their opinions about the length and content of residency had changed and whether they would still choose to be a physician and a family physician. RESULTS: Thirty-seven percent of responding third-year residents favored extending family practice residency to 4 years. Compared as groups, there was relatively little change in opinion between first- and third-year residents. However, residents' individual responses about the settings and content areas for which they would be willing to consider extending training varied considerably between years 1 and 3. Personal characteristics did not seem to influence residents' opinions about length and content of training. Reasons for favoring a 4-year program and barriers to change were similar to those reported previously. Residents' commitment to medicine and family medicine was still strong and was not associated with their opinions about length of training. CONCLUSION: Although most surveyed residents favored a 3-year residency program, a substantial minority still supported extending training to 4 years, and the majority would still choose to enter family medicine programs if they were extended. Given a lack of consensus about specific content areas, family medicine should consider a period of experimentation to determine how to best prepare future family physicians.

Adult↗