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Impact of the medical professional liability insurance crisis on access to care in Florida.

BACKGROUND: Almost half of the US states face serious problems with professional liability insurance (PLI). Despite this, little is known about how this crisis is affecting access to care, particularly in rural areas. METHODS: We surveyed physicians practicing in rural Florida in 2003. The primary assessment was on changes in health care delivery by service type and specialty. Secondary outcomes included changes in PLI premiums and the effect of changes in premiums on service delivery and practice satisfaction. RESULTS: Four hundred eleven (52.6%) of 781 physicians decreased or eliminated health care services during the past year. Overall, 73 (61.3%) of 119 decreased or eliminated vaginal deliveries; 60 (52.6%) of 114, cesarean sections; 186 (51.7%) of 360, hospital-based surgical procedures; 209 (46.4%) of 450, emergency department coverage; 103 (41.7%) of 247, endoscopic procedures; 187 (40.9%) of 457, office-based surgical procedures; and 105 (34.5%) of 304, mental health services. Elimination of services was highest for general surgeons (78.4%), surgical specialists (73.6%), and obstetricians/gynecologists (70.2%). Premiums for PLI rose a mean of 93.5%. Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years. CONCLUSIONS: The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide.

Adult↗

Availability of physician services in Florida, revisited: the effect of the professional liability insurance market on access to health care.

BACKGROUND: Access to care remains a key part of improving health care outcomes in the United States. Recent reports have suggested that the number of physicians able to meet the demands for access to care may be decreasing. METHODS: We surveyed physicians practicing in rural and urban/suburban areas of Florida in 2004 to determine whether changes were occurring in health care service delivery. Secondary outcomes assessed included changes in professional liability insurance and their possible effects on changes in service delivery. RESULTS: Overall, 727 (54.4%) of responding physicians stated that the delivery of services had been decreased or eliminated in the previous year. The most commonly eliminated services were nursing home coverage (42.1%), vaginal deliveries (29.1%), cesarean deliveries (26.0%), emergency department coverage (22.8%), and mental health services (21.2%). Surgical specialists (70.2%) and general surgeons (68.5%) were the groups with the highest number of decreased or eliminated services, but this trend was broad, with 63.6% of obstetrician/gynecologists and 60.2% of family medicine physicians also decreasing or eliminating services. Decreases in services seem to be related to changes in professional liability insurance premiums when assessed by both percentage of change and total premium increases for physicians. Rural and urban/suburban physicians did not differ significantly in these assessments. CONCLUSION: The findings suggest that physicians across Florida have continued to decrease or eliminate important health services and that these decreases seem to be related to the difficulty of finding or paying for professional liability insurance.

Florida↗

Strategies for reaching poor blacks and hispanics in Dade County, Florida.

A need to reach poor blacks and Hispanics in Dade County, Florida, with information about the prevention and early detection of cancer was documented in data from the Florida Cancer Data System for 1981 through 1983. This information was brought to the target population through community media, churches, and agencies serving the poor. Guidelines for productive presentations evolved during the 4-year experience. A significant portion of the community was recruited for mammograms. A significant change to in situ and local stage of disease occurred among the screened group as compared to an unscreened cohort treated at the same facility. An estimated savings of about $9700 in treatment costs per cancer found has shown that mammography of the poor community saves money as well as lives. The establishment of a One-Stop Breast Diagnostic Center compliments the screening program and removes many barriers in reaching the goal of early cancer detection among the poor.

Black or African American↗

Evaluation of the reliability and validity of the University of South Florida Environmental Assessment Questionnaire.

BACKGROUND: The National Institute for Occupational Safety and Health's (NIOSH) National Occupational Research Agenda (NORA), identified "exposure assessment methods" as a priority area for research in occupational medicine. METHODS: The University of South Florida Environmental Assessment Questionnaire (EAQ) describes exposures from the workers point of view. The questionnaire was distributed to a sample of workers drawn from a population of over 3,000 workers employed by a Florida food processing plant. The analysis of the validity was based on 211 subjects and the analysis of the reliability was based on 44 subjects. RESULTS: For the category scores, the sensitivities ranged from 0.67 to 1.0, the specificities ranged from 0.52 to 0.83, the positive predictive values ranged from 0.60 to 1.0, and the negative predictive values ranged from 0.55 to 1.0. All of the weighted kappas for the subcategories were above zero. The Spearman rank-order coefficients were above 0.5 for all of the exposure categories except the mold, plant, and animal exposure category which was 0.49. The correlation coefficient for the questionnaire as a whole was 0.85. CONCLUSIONS: This study showed the EAQ as a whole to be reliable and valid. Gathering valid occupational exposure information with this method was both feasible and economical.

Florida↗

Population history of native groups in pre- and postcontact Spanish Florida: aggregation, gene flow, and genetic drift on the Southeastern U.S. Atlantic coast.

Evolutionary trends and population history and structure are discussed for a series of late prehistoric and historic-period skeletal samples from the Georgia coast and interior (the Guale). Phenotypic dental measurement data were collected for nine samples from the late prehistoric (AD 1200-1400) and historic (AD 1608-1702) periods and subjected to population genetic and statistical analyses. The primary trends were for an increase in tooth size through time, and for an initial increase in dental variability in the early historic period, followed by a subsequent decline in dental variability in the late historic period. Given the increasing stress levels, evidenced by previous bioarchaeological analyses (Larsen [2001] Bioarchaeology of Spanish Florida, Gainesville: University Press of Florida), an environmental explanation for the increase in tooth size is unlikely. It is proposed that the early historic period witnessed aggregation and gene flow with extraregional populations, possibly African slaves or nonlocal Native American population groups. The late historic period may have experienced significant loss of phenotypic variability due to genetic drift. In both time periods, the evolutionary mechanism increased average tooth size, with independent variance effects.Because microevolutionary trends obscure patterns of gene flow and population ancestry, the data were detrended following Konigsberg ([1990a] Hum. Biol. 62:49-70), and submitted to standard population genetic analyses (Relethford et al. [1997] Hum. Biol. 69:443-465). Analysis of the precontact samples in isolation (Irene Mound, Irene Mortuary, and an aggregate coastal sample) indicated little genetic microdifferentiation (F(ST) = 0.008), limited extralocal gene flow, and a small distinction between interior and coastal samples. The inclusion of the historic data dramatically increased variability levels (F(ST) = 0.019). The analysis of extralocal gene flow indicates that the late mission period experienced significantly less external gene flow, which is consistent with historic models that suggest the social organization of the Guale during this time period may have been significantly altered. Genetic distances also indicate a primary division between inland and coastal precontact samples and a maintenance of biological populations along the coast. In other words, the coastal, early historic, and late historic period samples are phenotypically homogeneous, supporting the notion that the mission populations were drawn from the local population base. The late mission period sample was also, however, more closely related to the interior samples. This may suggest that the late mission period population was an aggregate sample composed of both remnant interior and coastal population groups.

Colonialism↗

Determining toxicity of leachates from Florida municipal solid waste landfills using a battery-of-tests approach.

The toxicity and physicochemical parameters of municipal solid-waste (MSW) landfill leachates from six sites in north and north-central Florida, United States, were determined. Landfill leachates are complex mixtures of organic and inorganic constituents. Leachate toxicity was assayed using the acute C. dubia (48-h) and Microtoxtrade mark (15-min) assays and the chronic S. capricornutum (96-h) assay. The landfill leachates were shown to be highly toxic to both C. dubia and S. capricornutum with an EC(50) < 10% and < 15%, respectively. However, Microtoxtrade mark was not as sensitive to the leachates. Based on these results, the assays were ranked for their sensitivities to the landfill leachates; C. dubia > S. capricornutum > Microtoxtrade mark. Chemical analyses showed high concentrations of un-ionized ammonia and salts in the landfill leachates but low concentrations of heavy metals. The toxicity of the landfill leachates varied between the sites sampled and within each of the landfill sites. A significant relationship was found between the total ammonia content of the leachates and toxicity as determined by the C. dubia and S. capricornutum assays. Although the chemical constituents in Florida MSW landfill leachates may be more dilute, the toxicity of the leachates is equivalent to that from industrial waste landfills.

Animals↗

Plasma steroid concentrations and male phallus size in juvenile alligators from seven Florida lakes.

Neonatal and juvenile alligators from contaminated Lake Apopka in central Florida exhibit abnormal plasma sex steroid concentrations as well as morphological abnormalities of the gonad and phallus. This study addresses whether similar abnormalities occur in juvenile alligators inhabiting six other lakes in Florida. For analysis, animals were partitioned into two subsets, animals 40-79 cm total length (1-3 years old) and juveniles 80-130 cm total length (3-7 years old). Plasma testosterone (T) concentrations were lower in small males from lakes Apopka, Griffin, and Jessup than from Lake Woodruff National Wildlife Refuge (NWR). Similar differences were observed in the larger juveniles, with males from lakes Jessup, Apopka, and Okeechobee having lower plasma T concentrations than Lake Woodruff males. Plasma estradiol-17beta (E(2)) concentrations were significantly elevated in larger juvenile males from Lake Apopka compared to Lake Woodruff NWR. When compared to small juvenile females from Lake Woodruff NWR, females from lakes Griffin, Apopka, Orange, and Okeechobee had elevated plasma E(2) concentrations. Phallus size was significantly smaller in males from lakes Griffin and Apopka when compared to males from Lake Woodruff NWR. An association existed between body size and phallus size on all lakes except Lake Apopka and between phallus size and plasma T concentration on all lakes except lakes Apopka and Orange. Multiple regression analysis, with body size and plasma T concentration as independent covariables, explained the majority of the variation in phallus size on all lakes. These data suggest that the differences in sex steroids and phallus size observed in alligators from Lake Apopka are not limited to that lake, nor to one with a history of a major pesticide spill. Further work examining the relationship of sex steroids and phallus size with specific biotic and abiotic factors, such as antiandrogenic or estrogenic contaminants, is needed.

Alligators and Crocodiles↗

Assessing state-wide biodiversity in the Florida Gap analysis project.

The Florida Gap (Fl-Gap) project provides an assessment of the degree to which native animal species and natural communities are or are not represented in existing conservation lands. Those species and communities not adequately represented in areas being managed for native species constitute 'gaps' in the existing network of conservation lands. The United States Geological Survey Gap Analysis Program is a national effort and so, eventually, all 50 states will have completed it. The objective of Fl-Gap was to provide broad geographic information on the status of terrestrial vertebrates, butterflies, skippers and ants and their respective habitats to address the loss of biological diversity. To model the distributions and potential habitat of all terrestrial species of mammals, breeding birds, reptiles, amphibians, butterflies, skippers and ants in Florida, natural land cover was mapped to the level of dominant or co-dominant plant species. Land cover was classified from Landsat Thematic Mapper (TM) satellite imagery and auxiliary data such as the national wetlands inventory (NWI), soils maps, aerial imagery, existing land use/land cover maps, and on-the-ground surveys. Wildlife distribution models were produced by identifying suitable habitat for each species within that species' range. Mammalian models also assessed a minimum critical area required for sustainability of the species' population. Wildlife species richness was summarized against land stewardship ranked by an area's mandates for conservation protection.

Amphibians↗

Mercury accumulation in largemouth bass (Micropterus salmoides) in a Florida lake.

Rates of mercury accumulation were examined in male and female largemouth bass (Micropterus salmoides) from Lake Tohopekaliga, Florida, to establish methods for fish consumption advisories for the protection of human health. In addition, concentrations were determined in five lower trophic level fish species. Total mercury concentrations in adult largemouth bass muscle tissue ranged from 0.16 to 1.10 micrograms/g (fresh weight) and increased as fish increased in size and age. Whole-body mercury concentrations of 1990 year-class largemouth bass increased from 0.05 microgram/g at 20 mm and to 0.32 microgram/g at 320 mm (age 2). Significant differences were found in the rates of accumulation between sexes for length and weight, but not for age. Therefore, standardized mercury concentrations were determined using bass age to make comparisons among sampling dates. Although there were significant differences in adjusted mean mercury concentrations among two sampling dates, mercury content of standard-age bass remained relatively constant over time. Largemouth bass exceed the Florida Health Advisory level for limited consumption of fish (0.50 microgram Hg/g) based on a mean concentration of 0.59 microgram/g for 64 bass. Advisories based on fish morphological characteristics (i.e., length, weight) or age are not possible for Lake Tohopekaliga due to differences in mercury accumulation in male and female bass. Lower trophic level species of sport fish did not exceed the limited consumption level.

Animals↗

Heavy metal and selenium levels in endangered wood storks Mycteria americana from nesting colonies in Florida and Costa Rica.

Colonially-nesting birds often nest in coastal areas, along rivers, or near other bodies of water that also are potentially polluted from industrial, agricultural or urban development. The levels of heavy metals and selenium were examined in the feathers of young wood storks Mycteria americana nesting in Northeastern Florida and from adult and young storks nesting on the Tempisque River on the west coast of Costa Rica. There were no significant yearly differences among the chicks from Costa Rica. Concentration of mercury, cadmium, and lead were significantly higher in the chicks from Florida compared to those from Costa Rica. Adult wood storks at Costa Rica had significantly higher levels of lead, cadmium, selenium, and manganese than young from the same colony.

Age Factors↗

An extramural dental education program in a rural setting in Florida.

An extramural dental education experience which is a required component of the University of Florida College of Dentistry is described. The program, established in 1977, is conducted on a contractual basis between the college and the Lafayette-Suwannee Rural Health Corporation, Inc., the governing body of the Dental Center clinic located in the town of Mayo, Florida, which is 65 miles from the dental school. The program has brought high quality comprehensive dental care to a previously underserved population. Dental students are provided with experiences that enhance social sensitization, and that are perceived by them as a help in bridging the gap between dental school and dental practice after graduation. The program has made valued contributions to the education, research, and service components of the dental school's mission.

Clinical Competence↗

Mineral status of grazing beef cattle in the warm climate region of Florida.

An experiment was conducted to determine the mineral status of purebred Brahman beef cattle grazing Bermuda--Bahia pastures grown on sandy, well-drained soils in Central Florida. Soil, plant, blood serum and liver tissue concentrations of calcium, potassium, sodium, magnesium, manganese and cobalt were generally adequate. Sixty-nine per cent of forages and 40% of serum samples were deficient in phosphorus. Seventy-five per cent of soils, 38% of forages and 18% of liver samples were deficient in copper. Sixty-nine per cent of forage samples were low, less than 30 ppm, in iron. All samples of forage, liver and serum were deficient in selenium. Likewise, all soil and forage samples and 47 and 88% of serum and liver samples, respectively, were deficient in zinc. Mineral elements most likely deficient and needed in supplements for grazing cattle on sandy, well-drained soils in the warm climate region of Central Florida are phosphorus, copper, selenium and zinc.

Animals↗

Long overlooked historical information on Agent Orange and TCDD following massive applications of 2,4,5-T-containing herbicides, Eglin Air Force Base, Florida.

BACKGROUND: From 1961-1971, The Air Development Test Center, Eglin Air Force Base (AFB), Florida, developed, tested, and calibrated the aerial spray systems used in support of Operation RANCH HAND and the US Army Chemical Corps in Vietnam. Twenty major test and evaluation projects of aerial spray equipment were conducted on four fully instrumented test grids, each uniquely arrayed to match the needs of fixed-wing, helicopter, or jet aircraft. Each of the grids was established within the boundary of Test Area 52A of the Eglin Reservation. METHODS: The tests, conducted under climatic and environmental conditions similar to those in Vietnam, included the use of the military herbicides (Agents) Orange, Purple, White, and Blue. Approximately 75,000 kg of 2,4,5-trichlorophenoxyacetic acid (2,4,5-T) and 76,000 kg of 2,4-dichlorophenoxyacetic acid (2,4-D) were aerially disseminated on an area of less than 3 km2 during the period 1962-1970. Data from the analysis of archived samples suggested that an estimated 3.1 kg of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), present as a contaminant, were aerially released in the test area. Because most of the vegetation had been removed before establishing the test site in 1961, there was an opportunity to follow ground-based residues independent of canopy interception, and the resulting high solar exposure of initial residues. Studies of the soils, fauna, flora, and aquatic ecosystems of the test grids and associated perimeters of Test Area C-52A (an area totally more than 8 km2) were initiated in 1969 and concluded in 1984. RESULTS AND DISCUSSION: Data from soil samples collected from 1974 through 1984 suggested that less than one percent of the TCDD that was present in soil when sampling began persisted through the ten-year period of sampling. More than 340 species of organisms were observed and identified within the test area. More than 300 biological samples were analyzed for TCDD and detectable residues were found in 16 of 45 species examined. Examination of the ecological niches of the species containing TCDD residues suggested each was in close contact with contaminated soil. Indepth field studies, including anatomical, histological and ultrastructural examinations, spanning more than 50 generations of the Beachmouse, Peromyscus polionotus, demonstrated that continual exposure to soil concentrations of 0.1 to 1.5 parts-per-billion (ng/g) of TCDD, had minimal effects upon the health and reproduction of this species. CONCLUSIONS: Since Agent Orange with its associated TCDD contaminant was aerially disseminated on the test grids, Test Area C-52A provided a 'field laboratory' for what may have happened in Vietnam, had there been no intercepting forest cover. However, in Vietnam a 'typical' mission would have disseminated 14.8 kg of 2,4,5-T/ha, most of which was intercepted by the forest canopy, versus the 876 kg 2,4,5-T/ha on the test grid at Eglin. Moreover, each hectare on the Eglin test grid received at least 1,300 times more TCDD than a hectare sprayed with Agent Orange in Vietnam. The disappearance or persistence of TCDD is dependent upon how it enters the ecosystem. Spray equipment test and evaluations missions at Eglin were generally scheduled and conducted with environmental conditions that were optimal for spray operations. This suggests that conditions favorable for dissemination of herbicide were the same conditions favorable for photodegradation of TCDD. It was likely that 99 percent of the TCDD never persisted beyond the day of application. No long-term adverse ecological effects were documented in these studies despite the massive quantities of herbicides and TCDD that were applied to the site. Reviews by the US Environmental Protection Agency and the National Academy of Sciences' Institute of Medicine did not address the fate of Agent Orange and TCDD as described in these studies from Eglin AFB, Florida.

2,4,5-Trichlorophenoxyacetic Acid↗

Acetylcholinesterase activity in grass shrimp and aqueous pesticide levels from South Florida drainage canals.

Freshwater drainage canals in South Florida are utilized to manage water in agricultural, urban, and water conservation areas and, as a result, collect urban and agricultural storm runoff that is discharged into the Atlantic Ocean and Gulf of Mexico. Pesticides in this runoff may be toxic to the biota inhabiting these waters. This study evaluated the effects of contaminants in South Florida canals draining into Biscayne Bay on the estuarine grass shrimp (Palaemonetes intermedius), a representative invertebrate species. Results of surface water analysis for pesticides indicated that eight pesticides out of 52 analyzed were detected. The herbicide metolachlor was found at all nine sites in the five canals sampled at concentrations up to 119 ng/L. Atrazine was detected at seven sites at concentrations up to 29 ng/L. Three organophosphate insecticides (chlorpyrifos, malathion, diazinon) were detected at three sites in two canals (Military and North). Grass shrimp from these three sites showed significantly reduced levels of the acetylcholinesterase enzyme as compared to control shrimp. These two canals are similar in the land use areas drained--urban and suburban and agriculture. The results suggest that monitoring organisms for AChE levels can be a means of detecting exposure to organophosphorus pesticide contamination.

Acetylcholinesterase↗

Pesticides in canals of South Florida.

Atrazine, ametryn, bromacil, simazine and norflurazon were the most frequently detected pesticides in surface water samples and DDE, DDD and ametryn were the most frequently detected pesticides in sediment samples collected over the period November 1991 to June 1995 in a monitoring network that includes 27 stations in south Florida canals. The 744 pesticide detections during this time period represent about 2% of the total number of analytical determinations. Many of the most frequently detected compounds were used in large amounts in the monitoring area based on pesticide usage estimates included in this study. Spatial trends in pesticide detections followed use patterns. The maximum atrazine detections occurred in winter to late spring and were associated with usage on turfgrass and agricultural products. Endosulfan residues above the Florida water quality criterion were occasionally observed in surface water in the Homestead area and most of the exceedences occurred in confined waters. Methods with lower MDLs have recently been developed and should increase the number of detections in future sampling. Pesticides which bind strongly to soil, pesticides that are highly persistent and those used in large amounts were some of the more frequently found pesticides in sediments.

Environmental Monitoring↗

Distribution of total mercury and methyl mercury in water, sediment, and fish from south Florida estuaries.

Concentrations of total mercury and methyl mercury were determined in sediment and fish collected from estuarine waters of Florida to understand their distribution and partitioning. Total mercury concentrations in sediments ranged from 1 to 219 ng/g dry wt. Methyl mercury accounted for, on average, 0.77% of total mercury in sediment. Methyl mercury concentrations were not correlated with total mercury or organic carbon content in sediments. The concentrations of total mercury in fish muscle were between 0.03 and 2.22 (mean: 0.31) micrograms/g, wet wt, with methyl mercury contributing 83% of total mercury. Methyl mercury concentrations in fish muscle were directly proportional to total mercury concentrations. The relationship of total and methyl mercury concentrations in fish to those of sediments from corresponding locations was fish-species dependent, in addition to several abiotic factors. Among fish species analyzed, hardhead catfish, gafftopsail catfish, and sand seatrout contained the highest concentrations of mercury. Filtered water samples from canals and creeks that discharge into the Florida Bay showed mercury concentrations of 3-7.4 ng/L, with methyl mercury accounting for < 0.03-52% of the total mercury. Consumption of fish containing 0.31 microgram mercury/g wet wt, the mean concentration found in this study, at rates greater than 70 g/day, was estimated to be hazardous to human health.

Animals↗

Metals and metalloids in tissues of American alligators in three Florida lakes.

Concentrations of metals and selenium were examined in tissues of American alligators (Alligator mississippiensis) from three lakes in central Florida, in one of which alligators have exhibited reproductive or developmental defects. Our overall objective was to determine whether the levels of metals were sufficiently high to confound the association between chlorinated hydrocarbons, which are elevated in eggs and juvenile plasma, and reproductive impairment. The concentrations of all metals were relatively low compared to those reported for alligators from elsewhere in Florida and the southeastern United States, suggesting that reproductive impairment is not due to metals and that metals pose no health risk to the alligators. We also wanted to determine whether skin, biopsied tail muscle, or tail tip tissue, all easily collected from live alligators, could be used as surrogate measures of internal tissue loads. Concentrations of arsenic, cadmium, chromium, lead, manganese, mercury, and selenium in liver were highly correlated with at least one of the three biopsied tissues. Only tin showed no significant positive correlation. No single tissue gave a high prediction of liver levels for all metals, although skin gave the highest correlation for mercury, and tail muscle gave the best overall correlation for lead and cadmium.

Alligators and Crocodiles↗

Evaluating ecosystem management capabilities at the local level in Florida: identifying policy gaps using geographic information systems.

Because ecosystem approaches to management adhere to ecological systems rather than human-defined boundaries, collaboration across jurisdiction, agencies, and land ownership is often necessary to achieve effective management of transboundary resources. Local natural resource and land use planners increasingly recognize that while ecosystem management requires looking beyond specific jurisdictions and focusing on broad spatial scales, the approach will partly be implemented at the local level with the coordination of local policies across larger landscapes. This article evaluates the collective capabilities of local jurisdictions to manage large transboundary ecological systems in Florida. Specifically, it combines plan evaluation with geographic information systems (GIS) techniques to map, measure, and analyze the existing mosaic of management across selected ecosystems in the southern portion of the State. Visual and statistical results indicate significant gaps in the management framework of southern Florida that, if filled, could achieve a greater level of consistency and more complete coverage of ecosystem management policies. Based on the spatial distribution of 58 ecosystem management indicators, notable gaps persist in the southwest coast, southeast coast, and central Everglades ecosystems, particularly for wildlife corridors and collaboration with neighboring jurisdictions. We also test for spatial autocorrelation of ecosystem planning scores and find that local jurisdictions with strong ecosystem management capabilities tend to cluster within specific ecosystems. Based on the findings, we make recommendations on how and where local plans can be strengthened to more effectively attain the objectives of ecosystem approaches to management.

Conservation of Natural Resources↗