Search PubMed⌕ Search

Biomedical subjects

Robert L Phillips

Publications and source records attributed to Robert L Phillips.

At least 37 records · Page 2Linked to original sources
PubMed2004

Modifiable determinants of healthcare utilization within the African-American population.

BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population. METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for Afrcan-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.

Adolescent↗
PubMed2003

Oral vitamin D3 decreases fracture risk in the elderly.

Vitamin D3 (or its physiologic equivalent, ergocalciferol), administered at a dose of 100,000 IU every 4 months for 5 years, is effective for primary prevention of fractures in the active elderly aged 65 to 85 years. This treatment regimen has no effect on cardiovascular, cancer, or all-cause mortality. Despite a seemingly large dose averaging 800 IU per day, this regimen is a safe, cheap (<$2 per year), and effective therapy for primary prevention of fractures.

Comment↗
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↗
PubMed2002

Accounting for graduate medical education funding in family practice training.

BACKGROUND AND OBJECTIVES: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding. METHODS: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs' knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. RESULTS: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME funding they received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%). CONCLUSIONS: More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.

Accounting↗
PubMed2002

Health care system and insurer support for smoking cessation guideline implementation.

Physician use of clinical practice guidelines (CPGs) is disappointingly low in the United States. Much emphasis historically has been placed on the individual clinician to implement use of guidelines in practice. Recently, the Public Health Service issued an updated set of smoking cessation guidelines that include recommendations not only for patients and physicians, but also for health care administrators, insurers, and purchasers. A random sample of Missouri family physicians and general internists was used to determine, for the first time empirically, whether physicians receiving external support for guideline implementation were more likely to adopt and adhere to guidelines in practice. Fewer than 20 percent of physicians receive system support consistent with the updated guideline for smoking cessation. Only 32 percent of physicians who are unaware of the guidelines receive any of the recommended external support, while nearly 60 percent of physicians who adhere to the guidelines in practice are receiving some form of external support. Thus, the fundamental issue that requires national attention is that successful guideline implementation is highly dependent on administrative supports from health care organizations and insurers.

Financial Support↗
PubMedDate not supplied

A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors.

BACKGROUND: Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. METHODS: Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. RESULTS: A chain of errors was documented in 77% of incidents. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients' requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. CONCLUSIONS: Cascade analysis of physicians' error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

Adolescent↗
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

Patients' beliefs about racism, preferences for physician race, and satisfaction with care.

PURPOSE: Few studies have attempted to link patients' beliefs about racism in the health care system with how they use and experience health care. METHODS: Using telephone survey data from a national sample of 1,479 whites, 1,189 African Americans, and 983 Latinos, we explored patients' beliefs about racism, their preferences for the race and ethnicity of their physician, and their satisfaction with that physician. A scale was developed to reflect patients' beliefs about racism. Race-stratified analyses assessed associations between patients' beliefs, racial preferences for physicians, choice of physician, and satisfaction with care. RESULTS: Among African Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African American physician (P <.001). Whereas only 22% of African Americans preferred an African American physician, those who preferred a African American physician and had an African American physician were more likely to rate their physician as excellent than did African Americans who preferred a African American physician but had a non-African American physician (57% vs 20%, P <.001). Latinos with stronger beliefs about discrimination in health care were more likely to prefer a Latino physician (P <.001). One third of Latinos preferred a Latino physician. Though not statistically significant, those who preferred and had a Latino physician rated their physician higher than Latinos who preferred a Latino physician but had a non-Latino physician (40% vs 29%). CONCLUSIONS: Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.

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

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

International medical graduates and the primary care workforce for rural underserved areas.

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

American Medical Association↗
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↗