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center projects New Projects Ongoing Projects Completed
Projects The
Development of a Model of Access to Nursing Background and objectives:
Nurses contribute to the overall social capital of organizations and communities
as well as serve as individual caregivers. However, the shortage of registered
nurses (RNs) raises concerns about the ability of the healthcare system
to provide adequate access to healthcare and to eliminate disparities
in health. The shortage also raises concerns about the efficacy of the
healthcare safety net. This nursing shortage may be enduring, with projections
of an inadequate nursing supply reaching as far into the future as 2020
(U.S. Department of Health and Human Services, 2002),
and 2030 (Spetz, 2005). These projections bring urgency
to gaining a better understanding of the impact of the nursing workforce
on access to care and population health. While projections of nursing supply and demand
receive a great deal of attention, very little attention has focused on
the impact of the aggregate nursing workforce on patient access to care,
processes of care, and/or contributions to population health. The integration
of several theoretical approaches may hold promise in helping us understand
these relationships. Social capital - or community capacity and social
networks -- has been linked to improved population health. Models of access
to care have identified factors related to improved health status, and
generally incorporate the aggregate health care system and/or external
environment (Anderson, 1995), or community resources
(Penchansky, & Thomas, 1981). Broad theories of the
social determinants of health also include patient or community use of
health services. However, these broad models may actually mask the potential
capacity or contributions of nursing to the health of the population.
Thus, theories that combine the concepts of social roles and clinical
capacity for specific professions are needed. Recent studies have documented important relationships
between a) nurse staffing and patient outcomes in acute care (Aiken
et al., 2002 & 2003; Kovner et al., 2002; Mark
et al., 2002 & 2004; Needleman et al., 2002), b)
nurse practitioners and patient outcomes in primary care (Brown
& Grimes, 1995; Laurant et al., 2005; Lenz
et al., 2004), and c) primary care and improved health outcomes (Parchman
& Culler, 1994; Shi et al., 2005). Unfortunately,
no analogous examination of nursing's influence on access to care or contributions
to population health outcomes has been conducted. The contributions of
the nursing workforce to population health are somewhat elusive because
of the difficulty in controlling other potential influences on patient
access to care, and/or population health outcomes. However, teasing out
these contributions will help to better understand how nursing supply
and demand may affect patient access to care and population health. There is currently a lack of theoretical and
empirical work linking the nursing workforce and health outcomes at the
population level. We propose to build upon the limited work on the topic
and expand our understanding of the nursing workforce by developing a
model of access to nursing care. We will also identify methodological
issues that must be addressed to test the relationship between nursing
and population health outcomes. Potential
policy relevance: The U.S.
is experiencing a persistent shortage of nurses. Even under non-shortage
conditions, one can surmise that the nursing workforce likely affects
patient access to care, care delivery and health outcomes. The current
situation, however, compounds the complexity of healthcare delivery, and
may create conditions under which imbalances may occur in access to care,
the actual delivery of care, and health outcomes and population health.
We propose a study that will provide insight into the relationship between
nursing and population health outcomes, knowledge that is critical to
address the current U.S. – and global – shortage of nurses.
This study will also provide policy-makers with information on nursing’s
contributions to healthcare and population health.
The work proposed here will build on previous BPHR efforts and complement
current and future BPHr initiatives by extending our knowledge of nursing’s
role in patient access to care and population health. (back to top) Physician Supply Modelling Review Background and objectives:
The BHPr supports two major and several minor workforce modeling projects.
The two major projects are focused on physicians and nurses. This project
focuses on physician supply and need modeling. There has not been a comprehensive
review of how the current physician models are developed, how they are
used, and what their impact has been. The goal of the project is to review the state of the
art of modeling in health workforce and to describe and discuss how modeling
has been useful and how it might be made more useful. The effort that
is currently underway with federal support represents only one type of
modeling; there has been no recent, extant review of the process for modeling
considering costs versus effectiveness versus accuracy. A general review
of the state of the art in workforce modeling would help us understand
that there are options to the current system and options that are likely
to be more appropriate for national workforce projections, especially
for physicians. The context for this proposed review needs to examine
the policy decision context for modeling; to ask what decisions can make
use of the information that comes from modeling and what the timeline
is for that decision making. For example, we need to have projections
of future supply to provide some estimate of the overall national (and
international) stock of physicians. This can be compared to projections
of need (or more simply, population) and this must be done in the context
of substitutes and complements. This national estimate of the balance
of supply and demand provides a sense of the overall market conditions
for physician training and can signal federal and state governments, professional
organizations and philanthropies, as to whether there needs to be expanded
or reduced support for training physicians or substitute and complements.
Potential
policy relevance: Physician
modeling is a core activity of the Bureau and the NCHWA, as such it should
be subject to periodic review and discussion. The value of the modeling
products of the Center can be increased by understanding how they have
been used in the past and how policy makers would like to see data come
from modeling Outcomes of Racially Matched Doctors and Patients in the Rural South Background and objectives:
It is widely believed that medical care is delivered best by physicians
whose race and ethnicity match that of the patient. Racial concordance
between patients and their physicians is thought to promote better communication,
better understanding and empathy (Cooper et al, 2003).
This in turn, is thought to promote more ready use of services and better
access, greater patient trust and satisfaction, more appropriate care
recommendations from physicians, greater adherence to physicians’
recommendations and ultimately better health (Cooper-Patrick
et al, 1999). Racial matching is embraced as a key approach to eliminating
racial health disparities in the US. Relatively few studies have verified the correlates
and outcomes of the racial matching of patients and physicians. In a recent
study using national data we found that African Americans who held stronger
beliefs about racism in the U.S. health care system were more likely to
prefer African American physicians, and those who preferred African American
physicians and whose usual source of care was indeed African American
were more satisfied with their physician than those who preferred African
American physicians but were cared for by White physicians (Chen
et al, 2005). There have been few assessments of the outcomes of racial
matching of patients and physicians; outcomes of available studies have
not all been positive (Howard et al, 2001). To our
knowledge, effects of patient-physician racial matching on visit rates,
use rates of recommended services and other access indicators have not
been studied, and outcomes for matching of rural minorities are particularly
understudied. The goal of this study is to assess how racial
discordance between African Americans and their physicians may be contributing
to racial health disparities in rural areas and, conversely, to assess
the promise expanding African American physician numbers might hold for
diminishing racial disparities in the future. Our objectives are to compare
a range of health care access, satisfaction and quality of care measures
for African American adults living in the rural Southeast whose usual
source of medical care is an African American physician versus White physician.
As a benchmark, this study will compare outcomes for African Americans
treated by African American and White physicians to outcomes for White
patients treated by White physicians.
Potential
policy relevance: The BHPr,
and HRSA more broadly, actively support increasing minority representation
in the health care workforce. HRSA’s Center of Excellence Program
serves as a national center for diversity and minority health issues (Gaston
and Horner, 2000). The Kids into Health Careers Program and National
Health Service Corps have explicit goals to assist in the preparation
and training of aspiring health care workers of all backgrounds. HRSA
identifies numerous programs targeting the elimination of health disparities
(HRSA, 2005). Section 747(c)(2) of the Public Health
Service Act, which funds programs to support the training of interns and
residents, directs the Secretary to give “priority in awarding grants
under this section to qualified applicants [organizations] that have a
record of training individuals who are from disadvantaged backgrounds
(including racial and ethnic minorities underrepresented among primary
care practice . . .)”. Promoting racial diversity in the health
professions is a key proposed bureau-level performance measure. Diversifying the racial-ethnic composition of
the US physician workforce is a goal of the Association of American Medical
Colleges and likely every medical school. The Institute of Medicine has
noted the need for more research to evaluate the impact of all types of
initiatives to remedy health disparities (IOM, 2003).
(back to top) Development
of Model Physician Data Standards Background and objectives:
State physician licensing systems have been a generally underused resource
for the gathering and reporting of national data on the supply and need
for physicians. This is due to the fact that the 50 states and the District
of Columbia all have different rules, regulations and methods for licensing
their physicians and collecting, analyzing and reporting data from those
license systems. However, those systems do include 100 percent of the
individuals who are able to practice medicine in their respective jurisdictions
and the states require regular renewals of those licenses which makes
those data, if retrievable, potentially the most timely available inventory
of practicing physicians in the nation. However, many states see the licensing
role as separate and distinct from reporting on the supply and demographics
of practitioners. Other states enthusiastically support the statistical
analysis of the data collected via the licensing process and those data
are used to make projections of supply and needs. North and South Carolina
and Iowa are examples of states that regularly use 100% license data to
report supply trends.
In cooperation with the AAMC and the Federation of State Medical Boards
(FSMB), we would help develop a minimum data set for physician registration
and annual updates. The goal is to help states develop useable and timely
data systems to allow them to understand their physician supply and capacity.
The project will be for one year.
Potential
policy relevance: The BHPr
has a responsibility for understanding the supply of and need for physicians
in the United States. Accurate data on national supply allows the Bureau
of determine the effects of its policies and programs on the supply and
distribution of physicians across the nation and meet its requirements
for accountability. Physician
Workforce Growth Among Counties in the Rural South: Background and objectives:
The relative shortage of physicians, especially those in the primary care
specialties, continues to challenge health and health care access in many
rural communities. Numerous federal, state, regional and community initiatives
have been undertaken over past decades to correct a physician shortage
problem that is presumed to be due to the inability of many rural communities
to recruit adequate numbers of physicians and also retain those they have.
Fixing a physician “recruitment and retention” problem is
an often-heard cliché in access-to-care circles. Despite long-held beliefs, there are no data
to suggest that rural shortage areas indeed develop due to problems in
both recruiting and retaining. What is most clearly known is only that
some areas don’t have enough physicians given their population size,
and whether they got that way due to problems in recruiting, retaining
or both, is less certain. Best current evidence suggests that rural underserved
areas suffer from poorer recruitment of physicians than non-underserved
rural areas (Langwell et al 1987; Li
1995; Wright 1985) but not from poorer retention
(Li 1995; Kindig et al 1992; Pathman
et al 2004). In a recent study (Pathman et al 2004)
we nevertheless advised that it was important for communities to address
both recruitment and retention in correcting shortages, the former because
it is most often the principal process leading to shortages and the latter
because the factors affecting retention are more often amenable to policy
interventions—improving physicians’ satisfaction, improving
physicians’ relationships with their communities, keeping on-call
frequencies manageable and enhancing physicians control and opportunities
for owning their practices. There are no data, however, confirming that
shortages are best corrected by addressing both recruitment and retention,
and when shortages improve for a community it is not known if it is typically
due to improvements in one or both processes. In sum, it is currently
not known whether resolution of physician shortages in rural areas typically
involve improvements in recruitment, retention or both and, consequently,
it is not known whether public and private initiatives to correct shortages
should be addressing recruitment, retention or both. The factors underlying
recruitment and good retention differ, therefore the appropriate initiatives
for addressing each process also differ.
The goal of this study is to characterize the recruitment and retention
dynamics underlying improvements in physician availability in shortage
areas of the rural South, for the purpose of helping the Bureau, its various
programs and other federal, state and community initiatives target the
most promising process(es) for alleviating shortages.
Potential policy
relevance: The Bureau of
Health Professions supports numerous programs whose principal or secondary
goals are to alleviate physician shortages by supporting recruitment,
retention or both. Top among these programs is the National Health
Service Corps, with its scholarship and loan repayment incentives.
The Bureau’s various primary care training programs—predoctoral,
residency, faculty development and Academic Administrative Units
grants—all aim to influence the future practice location of involved
learners and current practice location and work of teachers. Similarly
the Bureau’s Area Health Education Centers (AHECs), the
Quentin N. Burdick Rural Program for Interdisciplinary Training
and the Kids into Health Careers Program have strong rural recruitment
/retention components, as do some of the projects funded with the Bureau’s
Health Education and Training Center grants. By understanding
whether better recruitment or better retention most often underlies improvements
in rural physician shortages, all of these Bureau programs will more clearly
understand the most promising focus for their efforts and can refine their
operations accordingly. Other federal programs also aim to recruit or
retain primary care physicians in rural underserved areas, like the Medicare
Payment Incentive Program. These and numerous state programs (Pathman
et al 2000) and community initiatives that similarly will benefit
from understanding whether targeting recruitment or retention offers the
most promise for alleviating physician shortages. (back
to top) Technical
Assistance Network to Improve Health Workforce Data Collection and Reporting
in Southeast States Population
Characteristics and Nursing Employment Patterns Background and
Objectives: This project progresses from
the first year study entitled, "Differential Nursing Employment Patterns:
A Region IV Analysis of Race and Ethnicity," that provides a foundation
for examining another area of concern in the nursing workforce: the existence
and extent of discrepancy between the racial and ethnic composition of
the nursing workforce and the populations they serve. Individuals generally
prefer to receive health care from health professionals of the same racial
or ethnic background (Coffman, Rosenoff and Grumbach, 2001),
and recent studies report disparities between the nursing workforce and
the composition of the populations they serve in California (Dower
et al., 2001) and nationally (Buerhaus and Auerbach,
1999). The objective of this project is to compare the racial and
ethnic composition of the nursing workforce in Region IV with the populations
they serve. This comparison will determine if and where discrepancies
exist, and the extent of discrepancies within the region. County-level
data from the 2000 National Sample Survey of Registered Nurses will be
used to examine the demographics of the nursing workforce across within
the region, and urban or rural locations. Data for corresponding years
from the Area Resources Files (ARF), a national database representing
cross-sectional, county-level health resources information, will be used
to represent the population of Region IV. This database integrates data
from over 50 different primary data sources, including county-level information
on health facilities, health professionals, the population and vital statistics.
Potential policy relevance:
The policy goal is to aid in the development of geographically targeted
recruitment and retention strategies to ensure access to nursing care
in the region and in underserved areas within the region. Individuals
generally prefer to receive health care from health professionals of the
same racial or ethnic background, and studies report disparities between
the nursing workforce and the composition of the populations they serve.
Knowledge of the discrepancies will aid in the development of geographically
targeted recruitment and retention strategies to ensure access to nursing
care in the region and in underserved areas within the region. (back
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beliefs about racism, preferences for physician race, and satisfaction
with care. Annals of Family Medicine. 3:138-143.
Coffman JM, Rosenoff E, & Grumbach K. (2001). Racial/Ethnic disparities
in nursing. Health Affairs. 20(3): 263-272.
Cooper LA, Roter DL, Johnson RL, Ford ED, Steinwachs DM, Powe NR. (2003)
Patient-centered communication, ratings of care, and concordance of patient
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