Studies

Studies listed include those conducted by UW CHWS investigators including those conducted under the umbrella of the WWAMI Rural Health Research Center (RHRC), which is a close partner housed in the UW Department of Family Medicine.

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How Financial Support During the COVID Crisis Affected the Federally Qualified Health Center Workforce

Description of Research Study: When the COVID crisis took hold in the US in early 2020,...

How Financial Support During the COVID Crisis Affected the Federally Qualified Health Center Workforce

Description of Research Study: When the COVID crisis took hold in the US in early 2020, federally qualified health centers (FQHCs) had to quickly modify the way they deployed their health workforce to ensure patients had access to COVID testing while maintaining continued access to high quality primary care. Facing possible closures, even temporarily, spurred policymakers to provide access to emergency funds. This study examines what funds were made available to FQHCs, estimates how much FQHCs received during the crisis to date, and how receipt of funding relates to any modifications in FQHC staffing, including the use of virtual services and ensuring access to care for patients, as well as ensuring their safety. 

Purpose and Policy Relevance: The coronavirus disease (COVID-19) has brought a crisis to safety net providers across the United States. One large network of safety net providers includes federally qualified health centers (FQHCs) funded and authorized under the Section 330 of the Public Health Services Act and administered by the Health Resources and Services Administration (HRSA).i FQHCs serve over 28 million patients, primarily from underserved, low-income populations.ii The 1400 FQHCs provide critical primary care access as well as mental health and dental services across approximately 12,000 delivery sites in rural and urban areas.iii At least one in ten delivery sites were temporarily closed due to COVID-19 risk, and often in areas of critical need during the crisis.iv  

Several sources of funding emerged to support FQHCs during the COVID-19 crisis. The Coronavirus Aid, Relief, and Economic Security Act of 2020 (CARES Act) established the Provider Relief Fund, which has been allocated in “tranches” according to select characteristics of providers. For example, $15 billion was allocated to providers serving Medicaid/CHIP beneficiaries and $10 billion was allocated to rural providers. The general goal of these funds has been to provide financial protection to providers resulting from loss in patient revenue. In addition, supplemental funds were provided to support the purchase of COVID personal protective equipment (PPE) and testing supplies as well as to support the expansion of the use of telehealth.v FQHCs have been eligible to receive funding from a combination of sources. Despite this support, there is concern that the funding is not sufficient to prevent FQHCs from permanently closing and to serve areas in most need.vi  

This study aims to identify the sources and amount of funding received by FQHCs during this crisis, and how funding may have affected deployment and safety of their workforce to ensure continuous access to care for patients during the crisis. 

Design and Analysis: 

Study Questions:  

  • RQ 1: What have been the sources of COVID-related funding that FQHCs were eligible to receive since the start of the crisis, and what was the estimated amount received by each FQHC? 

  • RQ 2: How has COVID-related funding varied by 2019 FQHC characteristics such as funding level, patient case mix, location, services offered, and workforce mix? 

  • RQ 3: What, if any, relationships exist between COVID-related funding and FQHCs’ ability to remain open, serve a diverse community, provide virtual services, obtain adequate PPE and testing, and ensure the safety of their workforce? 

Study Design: This study is a retrospective analysis of FQHCs reporting in the 2019 Uniform Data System (UDS) with at least one response per month to the Health Center COVID-19 Survey.  

Approach: For RQ 1, we will develop a database with information on the amount and source of COVID-19 funding based on available federal datasets. We will identify which programs FQHCs were eligible for based on published criteria, which will assist in identifying the number of payments/programs FQHCs were qualified for in order to understand how the total payment was derived. Providers are identified by the facility name, city and state. The resulting database from RQ 1 will be merged with 2019 UDS based on facility name using a “fuzzy match” algorithm and manual matching for remaining low-scored matches to address RQ 2.vii This data will then be merged with responses from the COVID-19 Data Collection Survey Tool (approximately 70-80% response rate) based on grant number to address RQ 3. 

Assuming every FQHC received at least some funding (which preliminary analysis supports), we will calculate the amount of COVID-19 funding per patient and then categorize FQHCs into quartiles based on distribution of funding per patient. We will summarize patient and facility characteristics (including staffing) across funding quartiles. Similarly, we will determine whether federal funding is associated with FQHCs level of telehealth capabilities, COVID testing capacity and staffing capacity. 

Limitations: Funding such as from the Provider Relief Fund relied on application for funding and were not automatic, so an eligible provider may not have submitted an application to receive payment. Also, data are available on the total amount provided under the Provider Relief Fund but without detail on the source of funds and how many payments were allocated. A limitation of the UDS is that data are reported at the center level rather than at the delivery site level. UDS also restricts information on total staffing and source of revenue. 

Data Sources: For COVID-related funding, example sources of data include the CARES Actviii (e.g., Provider Relief Fund including General Distribution or Targeted Funds, FEMA Supplemental Fund), FY20 Coronavirus Emergency Supplemental Funding for Health Centersix, and FY20 Expanding Capacity for Coronavirus Testing Supplemental Funding for Health Centers.x Other potential sources of funding include the Payment Protection Program (PPP),xi Health Care Enhancement Act, and other foundation funding. FQHC patient and center characteristics will be obtained from the 2019 UDS. We will use weekly responses (approximate response rate of 70%) from the HRSA COVID-19 Data Collection Survey Tool, which includes data such as number of COVID tests, whether the center is temporarily closed, percent of visits that are conducted via telehealth, and percent staff available.xii  

Human Subjects Research: This study is not considered human subjects research due to the use of publicly available data reported at the site level. 

Page Break  

Timeline:  

Study 7-3: How Financial Support During the COVID Crisis Affected the Federally Qualified Health Center Workforce 

Month 

10 

11 

12 

Identify data sources for funding and create database 

Merge/clean weekly COVID data 

Merge funding dataset, weekly COVID data, and UDS 

Generate variables of interest and conduct analysis of datasets  

Draft and edit manuscript for publication 

Submit deliverables to NCHWA, and post on UW HWRC website 

Present findings at conferences 

In Progress HRSA: HWRC Allied Health 2021-02-02"
Shifting Roles and Skills of the Allied Health Workforce in Primary Care Due to Increased Use of Telehealth During the COVID-19 Emergency This study will examine how the roles and skills of allied health occupations in primary care have...
Shifting Roles and Skills of the Allied Health Workforce in Primary Care Due to Increased Use of Telehealth During the COVID-19 Emergency

This study will examine how the roles and skills of allied health occupations in primary care have changed during the COVID-19 pandemic in response to drastic increases in health care delivery using telehealth. We will review the literature and conduct key informant and clinic site interviews to describe how medical assistant and other key assistive occupations’ roles  have adapted to fewer in person visits and more use of distance technology, and will examine ways in which the changes were influenced by regulatory and payment policies. We will present policy and practice recommendations for ongoing support of the skills and competencies needed to effectively use telehealth by the allied health workforce in primary care.

Co-Leads: Susan M Skillman, MS and Tracy Mroz, PhD, OTR/L

Contact Info: skillman@uw.edu, tmroz@uw.edu

In Progress HRSA: HWRC Allied Health 2020-08-21"
Unintended Consequences of Academic Inflation This study will examine whether, and if so how, the composition of the student body including age,...
Unintended Consequences of Academic Inflation

This study will examine whether, and if so how, the composition of the student body including age, gender, and racial/ethnic mix has changed over time as educational requirements of a profession have increased. Focusing on a select number of health professions that have seen academic inflation, we will use a mixed methods approach to quantify the change as well as to understand the underlying reasons for the changes and attempts to mitigate any unintended consequences.

Co-Leads: Bianca K. Frogner, PhD and Tracy Mroz, PhD, OTR/L

Contact Info: bfrogner@uw.edu, tmroz@uw.edu

In Progress HRSA: HWRC Allied Health 2020-08-21"
Health Care Apprenticeships in the Time of COVID-19 Because of the COVID-19 pandemic, health care apprenticeship sites likely faced difficulties...
Health Care Apprenticeships in the Time of COVID-19

Because of the COVID-19 pandemic, health care apprenticeship sites likely faced difficulties maintaining the training programs while service volumes declined and/or clinics changed modes of delivery. The study’s objectives are to build on prior studies of medical assistant (MA) apprenticeships and describe how these programs were affected by the pandemic during both the initial response and the ongoing crisis, whether federal Disaster Recovery or other workforce development programs helped sustain the programs, how apprentices responded to the evolving clinic and learning environment following the initial shutdowns, and likely future directions for MA apprenticeships.

Co-Leads: Susan M Skillman, MS and Tracy Mroz, PhD, OTR/L

Contact Info: skillman@uw.edu, tmroz@uw.edu

 

In Progress HRSA: HWRC Allied Health 2020-08-21"
Growth and Sustainability of the U.S. Community Paramedic Workforce to Address Unmet Healthcare Needs Community paramedicine (CP) uses an existing workforce—emergency medical technicians (EMTs) and...
Growth and Sustainability of the U.S. Community Paramedic Workforce to Address Unmet Healthcare Needs

Community paramedicine (CP) uses an existing workforce—emergency medical technicians (EMTs) and paramedics—to provide multiple non-emergency services to facilitate patient access to the right care, in the right place, at the right time.1-3 CP is a relatively new role for out-of-hospital emergency medical services (EMS) personnel. In the nearly seven years since the development of a CP research agenda sponsored by the Agency for Healthcare Research and Quality,1 numerous questions about the CP workforce remain unanswered. The number of EMS agencies with CP programs around the U.S. has expanded from over 100 in 20144 to over 200 in 2017.5 As with all of EMS and health care, the COVID-19 pandemic has created challenges for CP but also opportunities to provide new services aimed at keeping people safe in their homes to reduce use of health care facilities and potential risk of exposure to COVID-19. These developments call for a new national study to answer important questions about this EMS workforce model that is still novel and emerging: What roles are community paramedics filling in the healthcare system? How do EMS organizations successfully staff CP programs? Do CP programs support the Quadruple Aim as it relates to provider satisfaction, resilience, and safety? How are program leaders sustaining this model?

Lead Researcher: Davis Patterson, PhD
Contact Info: davisp@uw.edu

In Progress HRSA: HWRC Allied Health 2020-08-21"
Exploring Health Workforce Influence on Equitable Care Delivery and Stigmatization toward COVID-19 Positive People of Color and People with Disabilities Diagnoses such as HIV/AIDS, mental illnesses, overweight, and sexually transmitted infections can...
Exploring Health Workforce Influence on Equitable Care Delivery and Stigmatization toward COVID-19 Positive People of Color and People with Disabilities

Diagnoses such as HIV/AIDS, mental illnesses, overweight, and sexually transmitted infections can carry social stigma, and individuals who are diagnosed with these diseases have been frequently stigmatized within the health care system. Using a Health Stigma and Discrimination Framework1, we will explore whether COVID-19 is developing into a stigmatized illness particularly among patients who are Black, Indigenous, and Other People of Color (BIPOC) and people with disabilities (PWD) who already experience discrimination in health care by interviewing frontline clinicians and leaders working with BIPOC and PWD diagnosed with COVID-19.

Co-leads: Danbi Lee, PhD, OTD, OTR/L, Janice Sabin, PhD, MSW

Contact Info: danbilee@uw.edu, sabinja@uw.edu

In Progress HRSA: HWRC Health Equity 2020-08-21"
The Role of Insurance Navigators in Mitigating the Financial and Health Risk of Unemployed Workers The Affordable Care Act implemented National Insurance Navigator Programs to have insurance...
The Role of Insurance Navigators in Mitigating the Financial and Health Risk of Unemployed Workers

The Affordable Care Act implemented National Insurance Navigator Programs to have insurance navigators assist the uninsured in signing up for health insurance. Since 2017, the federal administration has severely cut the budget for the National Insurance Navigator Program resulting in less help for the uninsured to find health insurance, especially for individuals with bilingual needs or more complicated cases. The COVID-19 pandemic has left millions of people without work and health insurance. Navigators are now to assist these millions of extra uninsured with severely tight budgets. Some navigators may have lost their jobs or be furloughed due to COVID risks, which adds further pressure on existing and struggling Navigator Programs. We will examine navigator employment situations before and after COVID-19 and the challenges these health workers face mitigating the financial and health risks of unemployed workers.

Lead Researcher:Marieke van Eijk, PhD
Contact Info:
mariev2@uw.edu

In Progress HRSA: HWRC Health Equity 2020-08-21"
Doula Project 2.0: Increasing the Use of Doulas by Underserved Communities Birth doulas help fill structural gaps in prenatal and maternal health care particularly in...
Doula Project 2.0: Increasing the Use of Doulas by Underserved Communities

Birth doulas help fill structural gaps in prenatal and maternal health care particularly in underserved communities. In our initial study on doulas conducted in year 2 of the HWRC, we examined the role of a doula, how they are trained, where they work, and what populations they serve. This study builds on that prior work by focusing on doulas who work with underserved and marginalized communities. We will gather data about the opportunities and challenges doulas face when serving underserved communities including the role of precarious wages, high turnover rates, and effects of institutionalized racism on health equity.

Lead Researcher: Marieke van Eijk, PhD
Contact Info: mariev2@uw.edu

In Progress HRSA: HWRC Health Equity 2020-08-21"
Lasting Effects of Continuing Education on the Topic of Implicit Bias in the Clinical and Learning Environment To date, few, if any, studies examine the lasting effects of continuing education on the topic of...
Lasting Effects of Continuing Education on the Topic of Implicit Bias in the Clinical and Learning Environment

To date, few, if any, studies examine the lasting effects of continuing education on the topic of implicit bias in healthcare. In this study we propose to re-contact participants in our study conducted in the 1st year of the HWRC titled, Implicit Race and Gender Bias, Bias Awareness, and Impact of a Course for Clinical Faculty, to determine whether there were lasting effects of exposure to the course on their teaching and clinical practice. In a brief survey, we will determine whether and in what ways they have applied this knowledge and/or perceived benefit of the course to clinical care and teaching in the time since exposure to the course. We will also seek their perspective on gaps in training, and potential next steps in continuing education and other interventions for implicit bias in health care.

Lead Researcher: Janice A. Sabin, PhD, MSW
Contact Info: sabinja@uw.edu

In Progress HRSA: HWRC Health Equity 2020-08-21"
Assessing the Size and Scope of the Pharmacist Workforce in the US In this study, we will assess the pharmacist workforce in the US by comparing information collected...
Assessing the Size and Scope of the Pharmacist Workforce in the US

In this study, we will assess the pharmacist workforce in the US by comparing information collected across public datasets. We will also use literature and key informant interviews to monitor emerging roles and skills in demand and to identify barriers and facilitators to expanding the pharmacist role to improve patient health.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

In Progress HRSA: HWRC Allied Health 2020-05-20"
What is Being Done to Prepare the Rural Health Workforce for COVID-19? Much of the attention is on urban centers during the COVID crisis. Rural communities are concerned...
What is Being Done to Prepare the Rural Health Workforce for COVID-19?

Much of the attention is on urban centers during the COVID crisis. Rural communities are concerned about the closure of hospitals and clinics during COVID. It is not clear which rural communities will experience a COVID surge and if there may be a delay in when it happens compared to urban regions. We will talk to key informants in rural areas to understand what they are doing to prepare for and respond to COVID and to what extent, if at all, health care workers are being redeployed and to where they are redeployed. We will conduct a scan of public sources (e.g., blogs, social media) as well as legislation and other state actions to determine how states and rural communities are directly addressing health workforce challenges in rural areas.
Lead Researcher: Davis Patterson, PhD
Contact Info: davisp@uw.edu

In Progress HRSA: HWRC Health Equity 2020-04-29"
What Types of Changes in Employment Status Have Been Most Common Among Health Care Workers as a Result of the COVID-19 Emergency? We are hearing of redeployments, furloughs, and layoffs, among other work status changes for health...
What Types of Changes in Employment Status Have Been Most Common Among Health Care Workers as a Result of the COVID-19 Emergency?

We are hearing of redeployments, furloughs, and layoffs, among other work status changes for health care workers across health care settings as a result of the COVID-19 emergency.  These terms are not used consistently and can result in confusion in descriptions of the state of the health workforce. Among the most common system changes affecting work status are reduced clinic volume and revenue, and surge-induced demand to care for COVID-19 patients. In describing the different employment changes, we will indicate which situations typically continue to confer some or all of the employees’ wages, which typically lead to unemployment claims, etc.  And we will discuss the settings (type of health care service delivered, size and characteristics of facility) that were/are more likely to redeploy, furlough, and/or lay off employees during the emergency.
Lead Researchers: Bianca K. Frogner, PhD and Susan Skillman, MS
Contact Info: bfrogner@uw.edu, skillman@uw.edu
 

In Progress HRSA: HWRC Health Equity 2020-04-29"
What Health Care Jobs and Skills in Demand During COVID-19?  We will use the job search engine Linkup to obtain data for the analysis of thousands of jobs...
What Health Care Jobs and Skills are in Demand During COVID-19?

We will use the job search engine Linkup to obtain data for the analysis of thousands of jobs posted calling for help in the COVID crisis. We will identify the occupations (including number) being called upon, for what purpose, and what region of the country.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

In Progress HRSA: HWRC Allied Health 2020-04-23"
How are the allied health workers being deployed during COVID-19? This study, similar to our recently releasedHow are Allied Health Workers Being Deployed During COVID-19?

This study, similar to our recently released rapid response brief on respiratory therapists, will produce more rapid responses for more occupations. We will investigate ways in which physical therapists, occupational therapists, social workers, home health aides among others are being utilized during COVID-19. We will add to this data on how many we have across states and describe what they do.
Lead Researcher: Susan Skillman, MS
Contact Info: skillman@uw.edu

Complete HRSA: HWRC Allied Health 2020-04-23"
Identifying the Barriers and Facilitators to Strengthen the Clinical Lab Professional Workforce This study is a collaboration between the University of Washington Center for Health Workforce...
Identifying the Barriers and Facilitators to Strengthen the Clinical Lab Professional Workforce

This study is a collaboration between the University of Washington Center for Health Workforce Studies (UW CHWS) and the American Society for Clinical Pathology (ASCP) to identify the existing approaches and strategies in place to recruit and retain clinical laboratory technicians and technologists, barriers and facilitators to strengthening the pipeline and current supply of clinical laboratory technicians and technologists in order to meet demand, and outline a blueprint for action to address existing barriers.
This study is funded by the  Siemens Foundation.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete Siemens Foundation 2020-02-11"
Washington State Behavioral Health Workforce Assessment 2019-2020 The 2019 Washington State Legislature charged the Washington Workforce Training and Education...
Washington State Behavioral Health Workforce Assessment 2019-2020

The 2019 Washington State Legislature charged the Washington Workforce Training and Education Coordinating Board (Workforce Board) to convene a work group to develop policy and practice recommendations to increase access to Washington’s behavioral health workforce. The recommendations, developed with stakeholders, will address the following barriers: a) reimbursement and incentives for supervision of interns and trainees; b) supervision requirements; c) competency-based training; d) licensing reciprocity or the feasibility of an interstate licensing compact, or both; and e) background checks, including barriers to work related to an applicant’s criminal history or substance use disorder. The University of Washington Center for Health Workforce Studies is collaborating with the Workforce Board to carry out this project. The legislation associated with this project directs that two reports will be produced, the first to be provided by December 1, 2019 and the second by December 1, 2020.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress Washington Department of Health 2019-10-10"
Washington State’s Nurse Workforce – 2019 This project will produce descriptions of the 2019 Washington state supply of Licensed Practical...
Washington State’s Nurse Workforce – 2019

This project will produce descriptions of the 2019 Washington state supply of Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and Advanced Registered Nurse Practitioners (ARNP)s using data collected from LPNs, RNs and ARNPs at state licensure and license renewal. These data, required for licensure, are being collected by Washington State Nursing Care Quality Assurance Commission and the National Council of State Boards of Nursing. The survey questions are drawn from the Nursing Minimum Data Set (employment status, job characteristics, demographics, education, and credentials). The resulting project report will summarize these demographic, education and work characteristics of the state nurse supply.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress Washington Center for Nursing 2019-10-10"
Criminal background checks and drug testing in health workforce employment: implications for health equity? This project will describe the commonalities and variability in policy related to the application...
Criminal Background Checks and Drug Testing in Health Workforce Employment: Implications for Health Equity?

This project will describe the commonalities and variability in policy related to the application of criminal background testing and drug testing in different health care settings and occupations, with an emphasis on those in behavioral health, as well as home and long term care settings. The extent to which these practices may influence health equity will be examined. Qualitative methods will include systematic literature reviews and interviews with key stakeholders.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Health Equity 2019-10-10"
Increasing Access to Doulas to Support a Diverse Population This study will describe the scope of practice of doulas in the US and how healthcare organizations...
Increasing Access to Doulas to Support a Diverse Population

This study will describe the scope of practice of doulas in the US and how healthcare organizations can invest in doula workforce development to increase access to doula services for underserved populations.
Lead Researcher: Marieke van Eijk, PhD
Contact Info: mariev2@uw.edu

In Progress HRSA: HWRC Health Equity 2019-09-10"
Disability Competency Training in Medical Education This study will investigate the current state of disability related trainings in medical education...
Disability Competency Training in Medical Education

This study will investigate the current state of disability related trainings in medical education programs to provide a foundation for recommendations for better integration of disability competency training in medical education.
Lead Researcher: Danbi Lee, PhD, OTD, OTR/L
Contact Info: danbilee@uw.edu

In Progress HRSA: HWRC Health Equity 2019-09-10"
The Potential Burden of Being Underrepresented in Health Professional Programs This study will have two purposes: (1) To compare the academic experience and level of perceived...
The Potential Burden of Being Underrepresented in Health Professional Programs

This study will have two purposes: (1) To compare the academic experience and level of perceived stress of non-URM health professional students to that of URM health professional students; (2) To examine the experience of URM health professional students and more specifically, to determine to what degree does the racial/ethnic diversity of a particular health professional cohort influence URM student perceptions of inclusion and affect their academic success.
Lead Researcher: Bernadette Williams-York, PT, DSc
Contact Info: yorkbern@uw.edu

In Progress HRSA: HWRC Health Equity 2019-09-10"
Best Practices in Experiential Education to Educate Health Professionals on Heath Equity This study will explore how experiential education is being used to train health professionals in...
Best Practices in Experiential Education to Educate Health Professionals on Heath Equity

This study will explore how experiential education is being used to train health professionals in SDOH and to achieve the goal of improving health workforce diversity to promote healthy equity. We will identify programs that incorporate experiential education curricula focused on SDOH and health equity, promising and best practices for experiential education, and community priorities for health professional education.
Lead Researcher: India J. Ornelas, PhD, MPH
Contact Info: iornelas@uw.edu

In Progress HRSA: HWRC Health Equity 2019-09-10"
Explaining Wage Variation Across Race/Ethnicity among RNs and APRNs This study will allow us to further understand wage differences across race/ethnicity among...
Explaining Wage Variation Across Race/Ethnicity among RNs and APRNs

This study will allow us to further understand wage differences across race/ethnicity among registered nurses (RNs) and advanced practice registered nurses (APRNs) using the most recent data the National Sample Survey of Registered Nurses (NSSRN) from the nation’s nurse workforce.
Lead Researcher: Susan Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Health Equity 2019-09-10"
Where and From What Industries are Health Care Workers Entering Health Care Jobs and Where are We Losing Them During COVID-19? With many jobs being lost in the economy, health care becomes an "attractive" though scary place to...
Where and From What Industries are Health Care Workers Entering Health Care Jobs and Where are We Losing Them During COVID-19?

With many jobs being lost in the economy, health care becomes an “attractive” though scary place to work. We will use the monthly Current Population Survey (CPS) data to track how displaced workers from other industries may be entering health care job. We will track which health care settings may be losing workers and in what jobs. We will analyze earnings and hours worked, which will inform our understanding of how “surge” may be addressed by just adding more hours to people’s time. In addition, we will study the potential tension between unemployment checks are a better deal compared to working in a hazardous job like health care at this time. We will also look at insurance status and child care support for some of the people in the sample but not all, which gives us a sense of how vulnerable the workers are and maybe look at how this breaks down by rural versus urban, race, and ethnicity.

In Progress HRSA: HWRC Allied Health 2019-09-10"
The Emergency Medical Services and Community Paramedic Workforces Respond to COVID-19 This study aims to understand how EMS personnel, particularly those in CP programs, are being...
The Emergency Medical Services and Community Paramedic Workforces Response to COVID-19

This study aims to understand how EMS personnel, particularly those in CP programs, are being deployed to respond to COVID-19 and how roles may have changed as a result of the public health emergency.
Lead Researcher: Davis Patterson, PhD
Contact Info: davisp@uw.edu

In Progress HRSA: HWRC Allied Health 2019-09-10"
Are Allied Health Providers Sick? If So, Are There Wage Consequences Associated with Being Sick? This study will examine the prevalence of mental illnesses among all working populations in...
Are Allied Health Providers Sick? If So, Are There Wage Consequences Associated with Being Sick?

This study will examine the prevalence of mental illnesses among all working populations in different industries in the U.S., and compare the prevalence of selected mental health disorders with workers in healthcare industry. This study will also examine the wage differences associated with mental health disorders among workers in different industries compared to those in healthcare industry.
Lead Researcher: Arati Dahal, PhD
Contact Info: aratid@uw.edu

In Progress HRSA: HWRC Allied Health 2019-09-10"
Occupational Therapists as part of the Behavioral Health Workforce This study will use a mixed methods approach to examine facilitators and barriers to occupational...
Occupational Therapists as part of the Behavioral Health Workforce

This study will use a mixed methods approach to examine facilitators and barriers to occupational therapy practitioners providing behavioral health care and opportunities for occupational therapy practitioners to help alleviate workforce shortages.
Lead Researcher: Tracy Mroz, PhD
Contact Info: tmroz@uw.edu

In Progress HRSA: HWRC Allied Health 2019-09-10"
What are Career Pathways to Registered Nursing? This study will use a nationally representative survey of Registered Nurses (RNs) to examine...
What are Career Pathways to Registered Nursing?

This study will use a nationally representative survey of Registered Nurses (RNs) to examine healthcare related jobs (if any) held by RNs before entering nursing education, and assess how RN careers at different education levels, delivery settings, and by RN demographic characteristics are associated with prior employment in healthcare.
Lead Researcher: Susan Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Allied Health 2019-09-10"
Health Workforce in Health Equity Research: Who, What, When, Where, and How This study will explore ongoing activity, opportunities, and gaps in research that addresses the...
Health Workforce in Health Equity Research: Who, What, When, Where, and How

This study will explore ongoing activity, opportunities, and gaps in research that addresses the role of healthcare workers in promoting health equity by examining online grants databases over the last decade. We will examine funding sources, occupations studied, outcomes examined, and grantee institutions among federally and privately funded research projects.
Lead Researcher: Marieke van Eijk, PhD
Contact Info: mariev2@uw.edu

In Progress HRSA: HWRC Health Equity 2019-04-22"
Racial/Ethnic Diversity in Associate Degree Programs in Nursing Associate degree programs in nursing (ADN) are said to provide an important entry point to...
Racial/Ethnic Diversity in Associate Degree Programs in Nursing

Associate degree programs in nursing (ADN) are said to provide an important entry point to diversifying the registered nursing field. However, little is known about the current racial/ethnic diversity of these programs, how it has been changing over time, and how it relates the sociodemographics of the overall institution. This study investigates the diversity of ADN programs and its correlates.
Lead Researcher: Selina Mohammed, PhD, MPH, RN
Contact Info: selinam@uw.edu

Complete HRSA: HWRC Health Equity 2019-04-22"
Implicit Race and Gender Bias, Bias Awareness, and Impact of a Course for Clinical Faculty This study examines whether exposure to a short course on implicit bias in the clinical and...
Implicit Race and Gender Bias, Bias Awareness, and Impact of a Course for Clinical Faculty

This study examines whether exposure to a short course on implicit bias in the clinical and learning environment, and strength of implicit race and gender bias, are associated with an increase in clinical faculty awareness of bias, change in bias awareness and development of strategies to improve patient care and teaching.
Lead Researcher: Janice A. Sabin, PhD, MSW
Contact Info: sabinja@uw.edu

In Progress HRSA: HWRC Health Equity 2019-04-22"
Examining Wage Disparities by Race and Ethnicity of Healthcare Workers This study examines the extent to which wage disparities exist between racial and ethnic groups...
Examining Wage Disparities by Race and Ethnicity of Healthcare Workers

This study examines the extent to which wage disparities exist between racial and ethnic groups within and across select healthcare occupations. This study also examines how healthcare wage disparities compare with other industries competing for labor.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

In Progress HRSA: HWRC Health Equity 2019-04-22"
Washington State’s Registered Nurse Workforce - 2018 The Washington Center for Nursing engaged the University of Washington Center for Health Workforce...
Washington State’s Registered Nurse Workforce – 2018

The Washington Center for Nursing engaged the University of Washington Center
for Health Workforce Studies to survey Washington’s registered nurses (RNs) in 2018
to provide up-to-date information about the state’s RN supply. The survey included
questions from the Nursing Minimum Data Set (employment status, job characteristics,
demographics, education, and credentials) as well as questions about satisfaction with
their current nursing position, career plans, salary, and employment history.
This study resulted in a full report that summarizes the findings from the Washington’s registered nurses survey. The full report can be found in the publications section of our website.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete Washington Center for Nursing 2018-12-20"
Supply of and Demand for Therapy Services in Skilled Nursing Facilities Little is known about the employment of therapy staff within skilled nursing facilities (SNFs)...
Supply of and Demand for Therapy Services in Skilled Nursing Facilities

Little is known about the employment of therapy staff within skilled nursing facilities (SNFs) relative to market needs. Therapy staff includes physical therapists (PTs), occupational therapists (OTs), physical therapy assistants (PTAs), occupational therapy assistants (OTAs), and therapy aides. The proposed study will compare wages and patterns of employment (e.g., full-time versus part-time, contracting, skill level- PT/OT versus PTA/OTA versus therapy aide) among therapy staff by market demand factors and SNF provider characteristics.
Lead Researcher: Tracy Mroz, PhD
Contact Info: tmroz@uw.edu

Complete HRSA: HWRC Allied Health 2018-07-02"
Leveraging Data Phase IV: Mapping Movement of Allied Health Professionals This study will examine available supply of allied health occupations by mapping where they live...
Leveraging Data Phase IV: Mapping Movement of Allied Health Professionals

This study will examine available supply of allied health occupations by mapping where they live and work, and how this pattern has changed over time. This is the fourth phase of a series of UW CHWS studies producing a robust data repository and body of research about the allied health workforce at the state and national level, with the goal of supporting future studies to inform policy makers and health workforce planners.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Allied Health 2018-07-02"
Apprenticeships as Pathways to Healthcare Careers: Experiences of Employers Using Medical Assistant Apprenticeships This study will examine the experiences of healthcare employers who are, and who are not, using...
Apprenticeships as Pathways to Healthcare Careers: Experiences of Employers Using Medical Assistant Apprenticeships

This study will examine the experiences of healthcare employers who are, and who are not, using Medical Assistant (MA) apprenticeships to sustain and expand their MA workforce. We will describe the range of employers’ experiences and factors likely to be associated with their decisions about whether or not to incorporate MA apprenticeship programs in their workforce planning.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Allied Health 2018-07-02"
Role of Allied Health Professions in Treating Pain Objective: Chronic pain is widespread among U.S. adults, and overreliance on pharmacological...
Role of Allied Health Professions in Treating Pain

Objective: Chronic pain is widespread among U.S. adults, and overreliance on pharmacological approaches to managing this pain has contributed to the nation’s opioid addiction crisis. There is growing recognition of the importance of directing patients towards non-pharmacological approaches to manage pain. This study describes the professions able to deliver evidence-based non-pharmacologic pain management, and how education-, policy- and practice-related factors serve as barriers or facilitators to further leverage these professions to effectively help manage pain.
Data/Setting: Literature reviews and interviews with key informants expert in evidence-based non-pharmacological pain management and the workforce who can provide these services.
Design/Methods: Building on recent systematic literature reviews of evidence-based non-pharmaceutical interventions for pain management from the Mayo Clinic and the U.S. Agency for Healthcare Research and Quality, we conducted a literature and web review to of health occupations able to provide these interventions. Commonly occurring chronic pain types addressed include: low back pain, chronic neck pain, knee osteoarthritis, fibromyalgia, and tension headaches. We also interviewed key informants about the policies, education/training, and perceived barriers and facilitators for increased use of these professions for non-pharmacological pain management.
Results: Chronic pain may be effectively managed using one or more evidence-based non-pharmacologic approaches. These approaches are within the scope of practice of multiple providers who may work individually or in multidisciplinary teams. Health care occupations identified as being able to deliver such approaches, in addition to the more typically recognized medical providers (physicians, nurse practitioners and physician assistants), include physical therapists and assistants, occupational therapists and assistants, massage therapists, athletic trainers, chiropractors, psychotherapists (licensed psychologists, licensed therapists/counselors and clinical social workers), and practitioners (standalone occupations or health care providers with added training) of acupuncture, yoga, tai chi, qigong, and Alexander technique. Education and credentialing requirements of these occupations vary widely.
Conclusions: As society works to reduce opioid addiction, efforts are increasing to improve access to the workforce providing non-pharmacologic pain management. Better education about the variety and availability of these practices is needed, as well as ongoing support for effectiveness research. Information about which occupations can provide evidence-based non-pharmacological pain treatment, where they are located, and which populations they are able to serve, may improve access to these services as well as identify gaps in the pain treatment workforce across the U.S. and where there is greater risk for overuse of pharmaceutical pain treatment. Reforms to insurance coverage and related reimbursement should be considered in order to improve access to these services.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2018-07-02"
Effects of Increasing Minimum Wage and Expanding Health Insurance Coverage on Job Stability among Long-Term Care Workers Recent efforts to raise the minimum wage rate across Washington State, along with expanded health...
Effects of Increasing Minimum Wage and Expanding Health Insurance Coverage on Job Stability among Long-Term Care Workers

Recent efforts to raise the minimum wage rate across Washington State, along with expanded health insurance coverage through the Affordable Care Act (ACA), may mitigate wage and health insurance barriers to steady employment. We will investigate how these policy changes influenced decisions by home health aides and home care aides to stay or leave the healthcare industry.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete UW Harry Bridges Center for Labor Studies 2017-10-04"
Trends in the Supply and Demographics of Oral Health Providers in Rural Communities, 2005-2015 Our study will use ten-years of data from the American Community Survey to compare the supply...
Trends in the Supply and Demographics of Oral Health Providers in Rural Communities, 2005-2015

Our study will use ten-years of data from the American Community Survey to compare the supply trends of dentists and dental hygienists in non-metro versus metro areas (proxies for rural and urban per available data). In particular, we will look at the aging trends among these providers, and additional demographics (e.g. gender, race/ethnicity) of these aging providers.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

In Progress HRSA: HWRC Allied Health 2017-10-03"
State Incentive Programs that Encourage Allied Health Professionals to Provide Care for Underserved Populations Objective: Incentive programs are a common strategy to address health professional shortages, and...
State Incentive Programs that Encourage Allied Health Professionals to Provide Care for Underserved Populations

Objective: Incentive programs are a common strategy to address health professional shortages, and this study sought to systematically describe allied health incentive programs at the state level (including the District of Columbia)—their goals, policies, practices, and available data on their success in allied health professional recruitment and retention to rural and underserved areas.
Data/Setting: Data came from online searches in all 50 states and DC as well as 30 semi-structured phone interviews with key informants from 27 states in 2018.
Design/Methods: We included programs providing financial support or training opportunities to students or professionals in return for a service requirement in a defined medically underserved setting (programs that only targeted physicians, dentists, nurses, physician assistants, or pharmacists were excluded). Interviews explored program goals, eligible professions, incentives offered, service obligations, facilitators and barriers to recruitment and retention, importance of incentive programs as a means of addressing allied health professional shortages, and program success.
Results: Most programs targeted allied health as well as primary care professionals such as doctors, nurses, and dentists. Non-allied health professionals often took priority over allied health in the allocation of incentives. Allied health professionals were eligible for incentives in 43 states and DC, and 16 states had more than one allied health program. 39 different types of allied health professionals were eligible for incentives; the most common types were behavioral or mental health professionals. Loan repayment, funded by states alone or in partnership with the Federal Health Resources and Services Administration, was the most common type of incentive, followed by scholarships and tax credits. Reported allied health professional recruitment and retention barriers included non-competitive salaries, lack of benefits and professional support, poor fit with rural communities, burnout, and lack of rural community infrastructure. Recruitment and retention facilitators included community engagement with program participants, competitive compensation, pre-existing commitment of applicants to rural or underserved area practice, professional support for work-life balance, and the natural environment.
Conclusions: We found that state programs frequently mirrored federal programs by offering loan repayment to a similar set of eligible occupations, including allied health. Programs often gave higher priority to primary care medicine, dentistry, nursing, and behavioral health occupations, while numerous allied health occupations outside of these categories were excluded from most states’ programs Overall, study participants thought their incentive programs were important in addressing allied health professional shortages with some noted challenges in measuring program impact.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Project Researcher: Davis Patterson, PhD
Contact Info: davisp@uw.edu

Complete HRSA: HWRC Allied Health 2017-10-03"
Leveraging Data to Monitor the Allied Health Workforce: Phase III This study will examine trends in the supply, distribution, and characteristics of 13 allied health...
Leveraging Data to Monitor the Allied Health Workforce: Phase III

This study will examine trends in the supply, distribution, and characteristics of 13 allied health occupations. It is a new (third) phase of a series of UW CHWS studies producing a robust data repository and body of research about the allied health workforce at the state and national level, with the goal of supporting future studies to inform policymakers and health workforce planners.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

In Progress HRSA: HWRC Allied Health 2017-10-03"
The Role of Apprenticeships in Meeting Employers’ Demand for Allied Health Occupations Objective: Nationwide, apprenticeship is being used as a tool to address difficult-to-fill health...
The Role of Apprenticeships in Meeting Employers’ Demand for Allied Health Occupations

Objective: Nationwide, apprenticeship is being used as a tool to address difficult-to-fill health care jobs, reduce turnover, and emphasize on-the-job learning, including for MAs. This study identifies key components of registered MA apprenticeship programs in the U.S. It describes implementation approaches and motivations for, as well as barriers and facilitators to, MA apprenticeships.
Data/Setting: Data came from a literature review and semi-structured phone interviews in 2018 and early 2019 with key personnel involved with registered MA apprenticeship programs in 11 states.
Design/Methods: Stakeholder interviews explored program origins, delegated responsibilities, and resources and challenges with starting and maintaining MA apprenticeship programs.
Results: Interviewees identified 23 active MA apprenticeship programs across a variety of health care settings. Programs demonstrated considerable flexibility, such as using both sequential and concurrent models for job-related didactic instruction and on-the-job learning components, as well as both time-based and competency-based approaches to measure apprenticeship progress. Most programs focused on training and upskilling incumbent workers, while some recruited apprentices from outside the organization. Program sponsors and employers needed adequate resources and personnel to administer and manage an apprenticeship program. Employers often faced difficulties filling mentor positions within their organization to train and support apprentices during on-the-job learning. Communication among apprenticeship partners was important and programs were most successful when employers were committed to the apprenticeship approach and viewed it as a long-term, organizational investment.
Conclusions: The majority of interviewees stated that employers used apprenticeship to upskill and train incumbent workers for the MA position, creating a pathway into new roles. Apprenticeship is not an immediate panacea, however, to solving gaps in MA workforce recruitment and training. This study found that MA apprenticeship programs supplement—rather than supplant—traditional MA education programs offered through public and private community and technical colleges. Apprenticeship requires financial investment from employers over a period of time before benefits are realized.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete HRSA: HWRC Allied Health 2017-10-03"
Allied Health Professionals and the “Gig Economy”: Trends in Alternative Work Arrangements In a recent study of the “gig economy,” or alternative work arrangement (e.g., self-employed,...
Allied Health Professionals and the “Gig Economy”: Trends in Alternative Work Arrangements

In a recent study of the “gig economy,” or alternative work arrangement (e.g., self-employed, freelancers, on-call, temporary workers, and contract labor), Katz and Krueger (2016) noted that healthcare was one of two industries (the other being education) that experienced the fastest growth of workers over the last decade. This study will expand on preliminary work on “gig” work among aides in long-term care (LTC) to investigate how trends in gig work has changed over time for allied health professionals, including aides; whether geographic patterns in the growth of the gig economy in healthcare relate to patient needs; how gig work has affected the wage rates over time; and whether any changes in gig work has impacted transition rates (exit or entry rates) of allied health workers.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

In Progress HRSA: HWRC Allied Health 2017-10-03"
Washington State Behavioral Health Workforce Assessment This study was conducted in collaboration with the Washington State Workforce Training and...
Washington State Behavioral Health Workforce Assessment

This study was conducted in collaboration with the Washington State Workforce Training and Education Coordinating Board. The purpose was to identify workforce-related issues that affect access to behavioral health care services in Washington. Many different occupations were found to comprise the overall behavioral health workforce, some providing solely behavioral care and others who had behavioral health along with medical care roles, such as in integrated behavioral/physical health settings. The assessment described and quantified the size, distribution, and education/training pathways of and demand for behavioral health occupations in Washington and uncovered some data limitations. With considerable stakeholder participation, policy and programmatic recommendations to address these workforce-related barriers were identified and, in January, 2018, were presented to the Governor and the 2018 Legislature and are described in the project’s reports.
This study resulted in a full report that can be found in the publications section of our website.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete U.S. Dept. of Labor, Workforce Innovation and Opportunity Act 2016-08-17"
Expanding Role of Medical Assistants Objective: Medical assistants (MAs) are a rapidly growing segment of the health workforce...
Expanding Role of Medical Assistants

Objective: Medical assistants (MAs) are a rapidly growing segment of the health workforce and
important members of the healthcare team. Demand for MAs is driven by pressure to reduce healthcare
expenses: labor costs to employ MAs are low relative to many other healthcare occupations and MAs’
education pathway is short. High MA turnover rates, however, are a commonly reported problem. This
study’s objective was to improve understanding of MAs’ careers and factors associated with their intentions
to remain in or leave the MA profession.
Data/Setting: MAs are not licensed in any state and Washington is rare by requiring MAs to be
credentialed and by defining MAs’ scope of (delegated) practice. These factors benefit this study of
Washington’s MA-Certified (MA-C) workforce by providing a relatively consistent study population in terms
of practice and education/training characteristics, and enhancing its generalizability to other states and MA
populations.
Design/Methods: For this survey of certified MAs sampled from state credential records, invitations were
emailed to all MAs with email addresses (11,790) and sent by USPS to a random sample (2,061) with
online and paper response options. Descriptive and regression analyses were conducted at statewide and
sub-state levels.
Results: The 3,355 responses (25%) closely mirrored the age and geographic distribution of
the state’s credentialed MA-Cs. Among 2,841 respondents working in a position requiring their credential,
93% were female, 88% worked in an office/clinic; 35% worked in primary care settings; 57% had less than,
and 33% held, an associate’s degree as their highest education credential; 54% obtained MA education
from a public and 41% from a private/for-profit institution; and statewide their mean hourly wage was
$19.91 (ranging from $16.80 to $21.80 among nine health planning regions). Slightly higher percentages of
MA-Cs were Hispanic and non-White compared with the overall 2016 state population. MA-Cs’ responses
to career/job satisfaction questions were generally very positive, although 41% disagreed with “I am
satisfied with opportunities for promotion at work”. More than half agreed with “I plan to seek training and/or
employment in another healthcare occupation in the next 5 years”. Hispanic (p<.05), Black (p<.001), and
Asian (p<.001) compared with White MA-Cs were more likely to express interest in seeking training or
employment in another occupation in healthcare while older MA-Cs and those with more years of MA work
experience were significantly less likely (both p<.001). Those who agreed with “I am satisfied with
opportunities for promotion at work” were significantly less likely to express interest in pursuing another
healthcare occupation (p<.001), while agreeing with “I feel overwhelmed by the amount of work that I am
given” was significantly associated with the interest (p<.001).
Conclusions: These findings suggest the MA occupation provides an entry to healthcare careers for
diverse populations. With more than half of Washington’s MA-Cs interested in leaving that occupation
within 5 years, retention strategies are needed, particularly targeting minority MA-Cs.
This study resulted in a published paper in the Journal of Medical Care Research and Review and a full report, both can be found in the publications section of our website.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete HRSA: HWRC Allied Health 2016-06-20"
Commuting Patterns of Allied Health Workers and Registered Nurses This study will assess how commuting impacts the availability of allied health professionals and...
Commuting Patterns of Allied Health Workers and Registered Nurses

This study will assess how commuting impacts the availability of allied health professionals and registered nurses in a community.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2016-06-20"
Scope of Practice Alignment of Emergency Medical Services Personnel This study will investigate how well the care provided by prehospital emergency medical services...
Scope of Practice Alignment of Emergency Medical Services Personnel

This study will investigate how well the care provided by prehospital emergency medical services (EMS) personnel align with their credentials and recommended scope of practice, and to what extent EMS providers practice at the top of their scope.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu

In Progress HRSA: HWRC Allied Health 2016-06-20"
Phase II of Leveraging Data for Allied Health Occupations This study expands the 2015-2016 study on Data for Phase II of Leveraging Data for Allied Health Occupations

This study expands the 2015-2016 study on Data for Allied Health Workforce Research by adding one to two new allied health occupations, and by adding new and updated data.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

In Progress HRSA: HWRC Allied Health 2016-06-20"
Multiracial Microaggressions in the Primary Care Setting This project focuses on exploring the racialized experiences of multiracial individuals and...
Multiracial Microaggressions in the Primary Care Setting

This project focuses on exploring the racialized experiences of multiracial individuals and families in the healthcare setting and the extent to which those experiences impact patient satisfaction outcomes, health-seeking behaviors, and patients’ provider preference. This study aims to further understand racial microaggressions and racial biases among healthcare providers and promote the provision of culturally relevant and responsive healthcare services for individuals and families of color, particularly the growing population of multiracial individuals and families.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

In Progress UW Patient-Centered Outcomes Research (PCOR) K12, Agency for Healthcare Research and Quality 2016-06-20"
National Family Medicine Graduate Surveys This study generates and revises national certification and recertification surveys of family...
National Family Medicine Graduate Surveys

This study generates and revises national certification and recertification surveys of family medicine physicians. (PI: Freddy Chen, Department of Family Medicine, UW School fo Medicine)

American Board of Family Medicine 2016-06-20"
The Impact of Medicare’s Rural Add-on Payments in Home Health on Access to Care and Home Health Markets This study assesses the impact of Medicare rural add-on payments on delivery of home health...
The Impact of Medicare’s Rural Add-on Payments in Home Health on Access to Care and Home Health Markets

This study assesses the impact of Medicare rural add-on payments on delivery of home health services. (PI: Tracy Mroz, Department of Rehabilitation Medicine, UW School of Medicine)
Lead Researcher: Tracy Mroz, PhD
Contact Info: tmroz@uw.edu, 206-598-5396

In Progress Agency for Healthcare Research and Quality 2016-06-20"
The Status of the Oral Health Workforce in Washington State This study used Washington state licensing data on dentists and hygienists; surveys of family...
The Status of the Oral Health Workforce in Washington State

This study used Washington state licensing data on dentists and hygienists; surveys of family physicians, pediatricians, and dentists; and key informant interviews with over 20 stakeholder organizations to provide a current assessment of Washington’s oral health workforce, including traditional oral health providers and physicians providing oral health preventive services.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete Washington Dental Service Foundation 2016-06-20"
Direct Access to Physical Therapists This study used commercial health insurance claims data to identify how health care utilization...
Direct Access to Physical Therapists

This study used commercial health insurance claims data to identify how health care utilization (e.g., imaging and opioid use) and spending patterns vary by whether the patient sees a physical therapist first or another provider. This study also looked at how state scope of practice laws allowing or restricting direct access to physical therapy impacts these patterns. This study was conducted under the State Health Policy Grant Program at the Health Care Cost Institute and in partnership with the National Academy of State Health Policy, and with sponsorship by the Arnold Family Foundation.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete Health Care Cost Institute/Arnold Family Foundation 2016-03-21"
Health Workforce Sentinel Network

The workforce is key to healthcare transformation, and to effectively meet transformation goals...

Health Workforce Sentinel Network

The workforce is key to healthcare transformation, and to effectively meet transformation goals the healthcare industry needs early signals of changes in the occupations, skills, and roles required by evolving healthcare systems.

The Washington State Health Workforce Sentinel Network (WSHWSN) supports efficient and effective health workforce preparation and deployment by:

  • identifying emerging signals of changes in health workforce demand, and
  • rapidly disseminating this information to education, training and policy partners who can take action based on findings.

Health workforce Sentinels:

  • help ensure the state’s health workforce is prepared to respond to the transforming health care environment,
  • have access to current and actionable information about emerging workforce needs, and
  • can compare their organization’s experiences and emerging workforce demand trends with similar employer groups.

Information provided by health workforce Sentinels are kept confidential and are reported in aggregate form, grouped with data from other similar organizations.

The Sentinel Network, is an initiative of Washington’s Health Workforce Council, conducted collaboratively by Washington’s Workforce Board and the University of Washington’s Center for Health Workforce Studies.
Funding to initiate the Sentinel Network came from the Healthier Washington initiative in 2016, with ongoing core support from Governor Inslee’s office and the Washington State Legislature.

Project Director: Susan M. Skillman, MS
Contact Info: skillman@uw.edu
Operation Director: Ben Stubbs, MPH
Contact: bstubbs@uw.edu
Health Workforce Sentinel Network in Other States
Connecticut
The Health Workforce Sentinel Network was introduced in Connecticut in Spring, 2019

In Progress WA - Washington State Legislature 2015-11-24"
Emerging Health IT Roles and Skillsets Objective: This study examined the value of Real-Time Labor Market Information (RT-LMI) for...
Emerging Health IT Roles and Skillsets

Objective: This study examined the value of Real-Time Labor Market Information (RT-LMI) for identifying how frequently, and for which occupations, skills related to health information technology (HIT) are specifically demanded by healthcare employers. The goal of this study was to understand the value and limitations of RT-LMI for monitoring health workforce demand, including allied health professions.
Data/Setting: We obtained a dataset from the job search engine company “LinkUp” of job ads posted in the fifty states and the District of Columbia during the 2015 calendar year. LinkUp provided the text information identifying the following fields: unique job identifier, employer/company name, job title, city, state, zip code, county, date posted, date created, date checked by LinkUp, job ad website url, and job description.
Design/Methods: The job descriptions were delivered as unstructured text strings that required additional coding to identify keywords of interest. Our study team developed a coding and parsing process to define the key variables of interests: occupation and HIT skills.
Results: Over 1.4 million records had one or more of the occupations from our designated healthcare occupation terms, and approximately half had a job description that could be used to search for skills required by the employer. The percentage of records with a job title and a job description that referenced a specific HIT skill varied greatly by occupation, with most occupations having fewer than 10% of records containing a HIT skill from our list of search terms. The 5 occupations with the highest percentage of job ads that referenced a specific HIT skill were: medical records and health information technicians, 60.4% of records; health educators, 19.5%; medical and clinical laboratory technologists, 17.0%; podiatrists and optometrists, 13.0%; medical assistants, 12.1%. Among our seven domains of HIT skills searched, the “health IT (general)” domain, comprised of search terms such as health information, health information technology, IT, or information technology, was most commonly identified (37.7% of records), and “privacy and security” (e.g., data security, cyber security, and risk analysis) was the least common domain (0.5% of records).
Conclusions: The patterns we found suggest that healthcare employers are requesting a range of HIT skills across occupations. Use of these data requires some caution and work to refine the data mining process.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2015-11-13"
Emerging Health IT Roles and Skillsets Objective: This study examined the value of Real-Time Labor Market Information (RT-LMI) for...
Emerging Health IT Roles and Skillsets

Objective: This study examined the value of Real-Time Labor Market Information (RT-LMI) for identifying how frequently, and for which occupations, skills related to health information technology (HIT) are specifically demanded by healthcare employers. The goal of this study was to understand the value and limitations of RT-LMI for monitoring health workforce demand, including allied health professions.
Data/Setting: We obtained a dataset from the job search engine company “LinkUp” of job ads posted in the fifty states and the District of Columbia during the 2015 calendar year. LinkUp provided the text information identifying the following fields: unique job identifier, employer/company name, job title, city, state, zip code, county, date posted, date created, date checked by LinkUp, job ad website url, and job description.
Design/Methods: The job descriptions were delivered as unstructured text strings that required additional coding to identify keywords of interest. Our study team developed a coding and parsing process to define the key variables of interests: occupation and HIT skills.
Results: Over 1.4 million records had one or more of the occupations from our designated healthcare occupation terms, and approximately half had a job description that could be used to search for skills required by the employer. The percentage of records with a job title and a job description that referenced a specific HIT skill varied greatly by occupation, with most occupations having fewer than 10% of records containing a HIT skill from our list of search terms. The 5 occupations with the highest percentage of job ads that referenced a specific HIT skill were: medical records and health information technicians, 60.4% of records; health educators, 19.5%; medical and clinical laboratory technologists, 17.0%; podiatrists and optometrists, 13.0%; medical assistants, 12.1%. Among our seven domains of HIT skills searched, the “health IT (general)” domain, comprised of search terms such as health information, health information technology, IT, or information technology, was most commonly identified (37.7% of records), and “privacy and security” (e.g., data security, cyber security, and risk analysis) was the least common domain (0.5% of records).
Conclusions: The patterns we found suggest that healthcare employers are requesting a range of HIT skills across occupations. Use of these data requires some caution and work to refine the data mining process.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2015-11-13"
Value of Athletic Trainers in Ambulatory Care Settings This study surveyed ambulatory care settings employing athletic trainers to understand the reasons...
Value of Athletic Trainers in Ambulatory Care Settings

This study surveyed ambulatory care settings employing athletic trainers to understand the reasons for hiring and the perceived value of athletic trainers to the practice.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete National Athletic Trainers' Association 2015-11-13"
Value of Athletic Trainers in Ambulatory Care Settings This study surveyed ambulatory care settings employing athletic trainers to understand the reasons...
Value of Athletic Trainers in Ambulatory Care Settings

This study surveyed ambulatory care settings employing athletic trainers to understand the reasons for hiring and the perceived value of athletic trainers to the practice.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete National Athletic Trainers' Association 2015-11-13"
Entry and Exit of Workers in Long-Term Care This study investigated the entry and exit trends over the last decade of workers in long-term care...
Entry and Exit of Workers in Long-Term Care

This study investigated the entry and exit trends over the last decade of workers in long-term care using the Current Population Survey. This study was conducted under a subcontract from the UCSF Health Workforce Research Center on Long-Term Care.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete UCSF Health Workforce Research Center on Long-Term Care 2015-11-13"
Impact of Electronic Health Records on Community Health Center Staffing This study examines the impact of the adoption of electronic health records on staffing...
Impact of Electronic Health Records on Community Health Center Staffing

This study examines the impact of the adoption of electronic health records on staffing configurations and thus productivity in community health centers. This study is conducted under a subcontract from The George Washington University Health Workforce Research Center.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete The George Washington University Health Workforce Research Center 2015-11-13"
The Role of Group Practice Managers in Veterans Healthcare System This study surveyed ambulatory care practices in the Veterans Healthcare System to evaluate the...
The Role of Group Practice Managers in Veterans Healthcare System

This study surveyed ambulatory care practices in the Veterans Healthcare System to evaluate the implementation of the initiative on Group Practice Managers, which aims to improve access to care for veterans. This study is in collaboration with the UW School of Public Health Department of Health Services.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete UW School of Public Health Department of Health Services 2015-11-13"
Impact of Innovations on Primary Care Workforce Configurations In this pilot, we conduct interviews with health care administrators to identify common themes on...
Impact of Innovations on Primary Care Workforce Configurations

In this pilot, we conduct interviews with health care administrators to identify common themes on how team-based care is employed in primary care settings in the WWAMI region Practice and Research Network (WPRN). This study is funded through the UW Institute of Translational Health Sciences.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete UW Institute of Translational Health Sciences 2015-11-13"
Big Data Study on Team-Based Care for Diabetes Patients This study used commercial health insurance and Medicare claims data to identify how health care...
Big Data Study on Team-Based Care for Diabetes Patients

This study used commercial health insurance and Medicare claims data to identify how health care utilization and spending patterns vary by the type of primary care provider seen. This study was conducted under a subcontract from the National Center for Interprofessoinal Education at the University of Minnesota.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete National Center for Interprofessoinal Education at the University of Minnesota 2015-11-13"
Does Unrestricted Access to Physical Therapy Reduce Health Spending? This study used commercial health insurance claims data to investigate whether timing of access to...
Does Unrestricted Access to Physical Therapy Reduce Health Spending?

This study used commercial health insurance claims data to investigate whether timing of access to physical therapists impacts health care utilization and costs for patients with lower back pain. This study was funded by the Health Care Cost Institute State Grant Program and the Arnold Foundation.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete Health Care Cost Institute State Grant Program and the Arnold Foundation 2015-11-13"
Educating Health Professionals to Address the Social Determinants of Health Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study...
Educating Health Professionals to Address the Social Determinants of Health

Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study Committee to develop a global framework on educating health professionals to address the social determinants of health.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete Institute of Medicine, National Academies of Science, Engineering and Medicine 2015-11-13"
Educating Health Professionals to Address the Social Determinants of Health Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study...
Educating Health Professionals to Address the Social Determinants of Health

Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study Committee to develop a global framework on educating health professionals to address the social determinants of health.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu, 206-616-9657

Complete Institute of Medicine, National Academies of Science, Engineering and Medicine 2015-11-13"
Wyoming Physicians Workforce This study offered data on the size, distribution, demographics, specialties and education history...
Wyoming’s Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Wyoming State’s physician workforce first conducted in 2014 and updated in 2016.

Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Wyoming Physicians Workforce This study offered data on the size, distribution, demographics, specialties and education history...
Wyoming's Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Wyoming State’s physician workforce first conducted in 2014 and updated in 2016.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Wyoming Health Care Workforce This study described Wyoming's health workforce to identify gaps in access to health care providers...
Wyoming Health Care Workforce Distribution and Policy Analyses

This study described Wyoming’s health workforce to identify gaps in access to health care providers and options for policy to alleviate health workforce shortages. The project used existing data on the state’s health workforce and provided technical assistance for ongoing data collection. This work was funded by the Wyoming Healthcare Commission.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
WWAMI Physicians 2005 This 2005 report examined the current supply and distribution of physicians in the WWAMI...
Physician Workforce in WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho): 2005

This 2005 report examined the current supply and distribution of physicians in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. The analysed utilized the 2005 AMA Masterfile to determine the population-based supply of physicians at the state and county level, analyzed by the discipline of physician. This report also shows the proportion, by specialty and state, who graduated from or trained at the University of Washington. Funded by the Department of Family Medicine, University of Washington.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
WWAMI Physician Workforce Education       Lead Researcher: Susan M. Skillman, MS Contact...
WWAMI Physician Workforce Education

 
 
 
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
WSU's Contributions to Nurse Supply This study examined how Washington State University's (WSU's) nursing programs contribute to the...
WSU College of Nursing’s Contributions to Washington State’s Nurse Workforce

This study examined how Washington State University’s (WSU’s) nursing programs contribute to the current supply of nurses in Washington and estimated the impact of the college’s graduates on future nurse supply in the state. Using available data, the project described registered nurse (RN) graduation trends from the WSU College of Nursing, estimated the number of WSU graduates in the current RN workforce in Washington, and estimated future WSU contributions to state nurse supply.

Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
WSU's Contributions to Nurse Supply This study examined how Washington State University's (WSU's) nursing programs contribute to the...
WSU College of Nursing's Contributions to Washington State's Nurse Workforce

This study examined how Washington State University’s (WSU’s) nursing programs contribute to the current supply of nurses in Washington and estimated the impact of the college’s graduates on future nurse supply in the state. Using available data, the project described registered nurse (RN) graduation trends from the WSU College of Nursing, estimated the number of WSU graduates in the current RN workforce in Washington, and estimated future WSU contributions to state nurse supply.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington's Radiographer Workforce This study examined Washington's radiographer supply and demand from 2000 through 2020. Readily...
Washington State's Radiographer Workforce Through 2020: Influential Factors and Available Data

This study examined Washington’s radiographer supply and demand from 2000 through 2020. Readily available literature and data permited an extremely limited analysis of trends in radiographer supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Washington's Pharmacist Workforce This study examined Washington's pharmacist supply and demand from 2000 through 2020. Readily...
Washington State's Pharmacist Workforce through 2020: Influential Factors and Available Data

This study examined Washington’s pharmacist supply and demand from 2000 through 2020. Readily available literature and data permited an extremely limited analysis of trends in pharmacist supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Washington's Oral Health Workforce, 2009 We analyzed available data on dentists, dental hygienists, and relevant populations to assess the...
Assessment of the Oral Health Workforce in Washington State

We analyzed available data on dentists, dental hygienists, and relevant populations to assess the size and distribution of the oral health workforce in Washington State. This included assessment of the current oral health workforce by analyzing DOH licensing records for dentists and dental hygienists and analyzing survey data for dentists and dental hygienists from the DOH health professions surveys conducted in 2007 and 2008; assessment of factors that affect future supply of dentists and dental hygienists, to include projections of retirement rates for dentists and dental hygienists and description of trends in educational output from Washington’s dentist and dental hygienist educational programs; and assessment of Medicaid oral health providers by county relative to the overall workforce and eligible populations, using data on Medicaid providers procured by DOH and available data on eligible populations. This study was funded by the Washington State Department of Health.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu

Complete 2015-09-25"
Washington's Dental Hygienists' Characteristics This study reported the results of a 2004 survey of dental hygienists in Washington State. Question...
Washington's Dental Hygienists: 2004 Survey Findings

This study reported the results of a 2004 survey of dental hygienists in Washington State. Question topics included demographics, practice characteristics, and job satisfaction. Funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.
Lead Researcher: Holly Andrilla, MS
Contact Info: hollya@uw.edu, 206-685-6680

Complete 2015-09-25"
Washington's Dental Hygienist Workforce This study examined Washington's dental hygienist supply and demand from 2000 through 2020. Readily...
Washington State's Dental Hygienist Workforce through 2020: Influential Factors and Available Data

This study examined Washington’s dental hygienist supply and demand from 2000 through 2020. Readily available literature and data permitted an extremely limited analysis of trends in dental hygienist supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Washington's Dental Hygienist Workforce This study examined Washington's dental hygienist supply and demand from 2000 through 2020. Readily...
Washington State's Dental Hygienist Workforce through 2020: Influential Factors and Available Data

This study examined Washington’s dental hygienist supply and demand from 2000 through 2020. Readily available literature and data permitted an extremely limited analysis of trends in dental hygienist supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.
Lead Researcher: Davis G. Patterson, PhD
Contact Info: davisp@uw.edu, 206-543-1892

Complete 2015-09-25"
Washington RNs' Characteristics 2007 In 2007, Washington State surveyed all of the licensed registered nurses (RNs) in the state to...
Demographic, Education, and Practice Characteristics of Registered Nurses in Washington State: Results of a 2007 Survey

In 2007, Washington State surveyed all of the licensed registered nurses (RNs) in the state to obtain basic demographic, education, and practice information. This study analyzed these survey responses and found that of all RNs with Washington licenses in 2007, 64% practiced in Washington, fewer than 10% were non-white, and 2% were Hispanic. Among Washington’s RNs, 49% worked in hospital inpatient settings and 62% provided direct patient care. The highest nursing degree attained by 43% of the state’s RNs was a BSN, and for 39% it was the ADN. Overall, 57% of Washington’s RNs obtained at least some of their nursing education in-state. RNs’ age at the time they obtained their initial nursing education was an average of nine years higher for those who obtained their degrees in 2005 or later than for RNs who obtained their degrees before 1980. More than 5% of RNs in Washington obtained their initial RN education outside of the United States. These demographic, practice, and education data provide policymakers, educators, and planners in Washington with useful information for assessing the status of Washington’s RN workforce.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington RN Supply and Demand to 2031 This study projected trends in the supply and demand of registered nurses (RNs) in Washington State...
Projections of Washington State RN Supply and Demand through 2031

This study projected trends in the supply and demand of registered nurses (RNs) in Washington State from 2005 through 2031. The project used available data on RNs in the state to estimate the influence of different factors on RN supply and demand across 20 years (2011-2031). Another goal of the project was to describe the limitations of the models and the types of data that would improve the accuracy of these models in the future. Funded by the Washington Center for Nursing through Department of Health grant #N14191.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington RN Supply and Demand to 2025 This study projected trends in the supply and demand of registered nurses (RNs) in Washington State...
Projections of Washington State RN Supply and Demand through 2025

This study projected trends in the supply and demand of registered nurses (RNs) in Washington State from 2005 through 2025. The project used available data on RNs in the state to estimate the influence of different factors on RN supply and demand across 20 years. Another goal of the project was to describe the limitations of the models and the types of data that would improve the accuracy of these models in the future. Funded by the Washington Center for Nursing through Department of Health grant #N14191.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington Registered Nurse License Expirations 2008-2014 These analysed of Washington State registered nurse professional license data examined changes in...
Washington State Registered Nurses – Analysis of RNs who did not renew their licenses: 2008-2014

These analysed of Washington State registered nurse professional license data examined changes in the numbers and ages of RNs whose licenses expired from 2008 to 2014. Results included the findings that RN licenses expiring annually in Washington increased in both actual numbers and in the percentage of the total RN supply, and the greatest increase was among the oldest RNs (age 60-75).
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington Physicians This study offered data on the size, distribution, demographics, specialties and education history...
Washington State's Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Washington State’s physician workforce first conducted in 2014 and updated in 2016.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington Obstetrical Providers and Liability Insurance Obstetrical providers (obstetrician/gynecologists, family physicians, certified nurse midwives and...
Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State

Obstetrical providers (obstetrician/gynecologists, family physicians, certified nurse midwives and licensed midwives) were surveyed in 2004 to assess their demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetrical practices, and obstetrical practice environment changes. Funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Washington Obstetrical Care This completed study characterized the distribution and supply of male and female obstetricians and...
Obstetrics and Gynecology Specialty Services: Supply, Distribution, and the Effect of Changing Demography in Washington State

This completed study characterized the distribution and supply of male and female obstetricians and gynecologists (ob-gyns) in Washington State, as well as the services they provide. This study used a cross-sectional analysis of 1998-1999 state licensing data linked with supplemental survey data. Findings show a significant shortage of ob-gyns, especially female ob-gyns, in rural areas. Funded by HRSA, National Center for Health Workforce Analysis.

Complete 2015-09-25"
Washington LPNs' Characteristics 2007 In 2007, Washington State surveyed all of the licensed practical nurses (LPNs) in the state to...
Demographic, Education, and Practice Characteristics of Licensed Practical Nurses in Washington State: Results of a 2007 Survey

In 2007, Washington State surveyed all of the licensed practical nurses (LPNs) in the state to obtain basic demographic, education, and practice information. This report describes LPNs in Washington using the 2007 survey responses, weighted to reflect the overall population. The descriptive statistics reflect LPNs who live in-state, and some sub-state analyses are provided. Of the 14,446 LPNs with Washington licenses in 2007, 72% practiced in Washington. The work setting in which the largest percentage were employed was long-term care (37%), and 65% of licensed LPNs in Washington reported they worked in primary care. Of the average 37 hours worked per week by LPNs, 25 hours on average were spent in direct patient care. The average age of practicing LPNs was 46, 12% were male, 18% were non-white, and 4% were Hispanic. Nearly three-quarters of Washington’s licensed LPNs received their LPN education in-state. Less than 2% of LPNs in Washington obtained their initial LPN education outside of the United States. Because of the high average age of Washington’s LPNs, the relatively slow rate at which the workforce is growing, and the fact that LPNs provide significant amounts of long-term and home care services, there is concern that the workforce may not be adequate to meet future needs. Subsequent surveys will allow examination of LPN workforce trends over time and assessment of the impact of health workforce-related decisions and policies now being implemented.
Lead Researcher: Holly Andrilla, MS
Contact Info: hollya@uw.edu, 206-685-6680

Complete 2015-09-25"
Washington LPN Supply and Demand to 2025 This study projected trends in the supply and demand of licensed practical nurses (LPNs) in...
Projections of Washington State LPN Supply and Demand through 2025

This study projected trends in the supply and demand of licensed practical nurses (LPNs) in Washington State from 2007 through 2025. The project used available data on LPNs in the state to estimate the influence of different factors on LPN supply and demand across nearly two decades. Funded by the Washington Center for Nursing through Department of Health grant #N14191.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington Hospital Staffing With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in...
Washington’s Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005

With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in Washington State in 2001, 2002, 2004, and 2005 to determine employment, contracting, and vacancy rates for 21 occupational categories, level of difficulty recruiting those staff, and level of difficulty credentialing physicians. Responses were analyzed at the level of state, hospital size, and workforce development area. The 2001 survey asked more detailed questions about the hospital nurse workforce; the 2002 and later surveys included questions about the hospital physician workforce. These studies were funded by HRSA’s National Center for Health Workforce Analysis (including through a Congressional Appropriation to the UW CHWS) and by the Health Work Force Institute of the Washington State Hospital Association.

Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington Hospital Staffing With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in...
Washington's Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005

With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in Washington State in 2001, 2002, 2004, and 2005 to determine employment, contracting, and vacancy rates for 21 occupational categories, level of difficulty recruiting those staff, and level of difficulty credentialing physicians. Responses were analyzed at the level of state, hospital size, and workforce development area. The 2001 survey asked more detailed questions about the hospital nurse workforce; the 2002 and later surveys included questions about the hospital physician workforce. These studies were funded by HRSA’s National Center for Health Workforce Analysis (including through a Congressional Appropriation to the UW CHWS) and by the Health Work Force Institute of the Washington State Hospital Association.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Washington ARNPs' Characteristics 2008 In 2008, Washington State surveyed all of the licensed advanced registered nurse practitioners in...
Demographic, Education, and Practice Characteristics of Advanced Registered Nurse Practitioners in Washington State: Results of a 2008 Survey

In 2008, Washington State surveyed all of the licensed advanced registered nurse practitioners in the state to obtain basic demographic, education, and practice information. This study analyzed these responses in order to provide policymakers, educators, and planners in Washington with useful information for assessing the status of Washington’s ARNP workforce.
Lead Researcher: Susan M. Skillman, MS
Contact Info: skillman@uw.edu, 206-543-3557

Complete 2015-09-25"
Veterans' Pathways to Allied Health Issue: Over the next five years, approximately 1.5 million military service members will separate...
Pathways for Military Veterans to Enter Allied Health Careers

Issue: Over the next five years, approximately 1.5 million military service members will separate from the military. As a growing industry, healthcare may hold job opportunities, especially for entry level allied health positions, that are ideal for military veterans transitioning into the civilian sector. Anecdotal evidence suggests that many veterans, including those with healthcare experience, have difficulties entering civilian healthcare occupations. This study investigates veterans’ barriers to career transitions into healthcare careers, particularly allied health careers, and examines the types of programs and policies designed to assist veterans to overcome barriers in their pursuit of healthcare careers.
Methods: This descriptive study draws from a review of published and gray literature, as well as a review of enacted state legislation.
Findings:

  • Four thematic areas emerged from the literature on the barriers that veterans frequently face when pursuing healthcare careers: 1) navigating complex benefits, 2) translating military education and training to meet civilian academic requirements, 3) meeting credentialing requirements, and 4) overcoming limited communication and knowledge about healthcare career opportunities.
  • Most state legislative efforts focused on emergency medical service and nursing occupations. Most state efforts were aimed at helping veterans meet credentialing requirements, including applying military education and experience to meet licensing requirements, as well as helping veterans translate military education and training into civilian occupations.
  • Several individual institutions, organizations, and government entities have introduced or changed existing policies and/or provided funding to support veterans’ education and employment programs to assist veterans’ transitions to civilian employment. Most of these programs address the barrier of translating military education and training to meet civilian academic requirements.
  • Few efforts were found that were aimed at increasing awareness about healthcare career opportunities.

Discussion: State and federal policymakers, educational institutions, and veteran support organizations have been developing ways to help veterans transition into healthcare jobs.  As programs and efforts mature, high-quality, sustained evaluation and assessment are needed to understand how well the efforts are meeting their goals and the needs of veterans, as well as to identify areas for improvement, additional support, and replication in other settings.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.

Complete HRSA: HWRC Allied Health 2015-09-25"
Veterans in Allied Health Objective: The goal of this study was to explore how veterans in healthcare occupations compare to...
Characteristics of Veterans in Allied Health Care Jobs

Objective: The goal of this study was to explore how veterans in healthcare occupations compare to their civilian counterparts.
Data/Setting: We used the 2011-2013 American Community Survey (ACS), which is a household survey conducted annually by the U.S. Census Bureau. We restricted our analysis to the non-institutionalized population age 18 to 75 years old living in the 50 states and the District of Columbia. We used pre-defined stratified sample probability weights to make the sample nationally representative and identified individuals working in healthcare occupations as classified by four-digit Census occupation codes.
Design/Methods: Sociodemographic characteristics of the study population were compared by veteran status and gender, and unpaired two sample t-tests were conducted to determine significant differences across mean characteristics by gender and by veteran status. Pearson’s chi-squared test was used to determine significant differences in proportions across veteran status within gender. Statistical significance was determined at p<0.001.
Results: Healthcare from 2011 to 2013 was a female-dominated field among non-veterans, (79.7% female) but among veterans, the gender distribution was nearly reversed (32.0% female). Generally, veterans had a lower percentage of females in every occupation compared to non-veterans. Among veterans, female veterans working in a healthcare occupation were significantly likely to be younger, not married, working part-time, below the poverty level, and receiving lower average individual earnings than male veterans. Allied health professions such as diagnostic related technologist/technician (e.g., cardiovascular technologist/technician, sonographer, magnetic resonance imaging technologist) were among those most commonly held occupations by veterans across both genders, but with higher frequency among males. Female veterans and non-veterans were more likely to be in lower-skilled occupations like nursing/psychiatric/home health aide, medical assistant, and personal/home care aide compared to their male counterparts. About 40% of veterans under age of 25, either gender, were in low-skilled aide and assistant positions; this was significantly higher than among young non-veterans.
Conclusions: Given that healthcare occupations are in high demand for the foreseeable future and veterans are currently underrepresented in the field, young veterans struggling to find employment should be encouraged to consider opportunities in healthcare. Reflective of the larger veteran population, veterans working in healthcare were largely an older male population that is relatively well-educated and working in highly skilled occupations. Young veterans, on the other hand, were more likely to be in assistive entry-level occupations regardless of gender. The nation’s challenge is to ensure that veterans and nonveterans who enter healthcare occupations enter at the highest level their education and training supports, and that they have trajectories that encourage career advancement and upward mobility. More work is needed to understand the underlying factors (e.g., military training and experience, financial support for education from the GI bill) that led male veterans to more highly skilled and higher-paying occupations in healthcare.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2015-09-25"
Unhealthy Lifestyles of Rural/Urban Minorities: Obesity Background: Obesity is on the rise in the United States and has been implicated in...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity

Background: Obesity is on the rise in the United States and has been implicated in serious chronic health problems. Obesity is very costly in terms of medical spending and lost productivity. Aim: To estimate the prevalence of and recent trends in obesity among U.S. adults residing in rural and urban locations.
Methods: A telephone survey of adults aged 18 years and older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS) in 1994-1996 and 2000-2001. The main outcome measure for the study was obesity, defined as a body mass index of 30 or greater, based on self-report.
Results: In 2000-2001, the prevalence of obesity was 23.0% for rural adults and 20.5% for their urban counterparts, increases of 4.8% and 5.5%, respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties of Mississippi, Texas and Louisiana. Only Rhode Island and Colorado had rural counties that met the HealthyPeople 2010 goal of a maximum of 15% obese for adults.
Conclusions: Despite recent attention to the prevalence of obesity, obesity rates continue to rise across the United States and differentially affect inhabitants of rural and urban areas. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Unhealthy Lifestyles of Rural/Urban Minorities: Cigarettes Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim:...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking

Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim: To estimate the prevalence of and recent trends in smoking among adults residing in three types of rural locations. Methods: Telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 and 2000-2001. Results: The prevalence of smoking changed little from the mid-1990s; it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural non-adjacent areas, and 24.9% in small rural non-adjacent areas. For rural locations combined, its prevalence was not below the 12% goal of HealthyPeople 2010 for any state. Its prevalence was ≥ 28% for rural residents of Kentucky, Ohio and Indiana. Since the mid-1990s, the prevalence of smoking for rural respondents decreased by more than 2% in California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2% or more in Alabama, Delaware, Georgia, Massachusetts, Michigan, Mississippi, New Hampshire, Oklahoma, South Carolina, and Texas. Conclusions: Smoking remains a refractory public health problem. Better ways to curb smoking in rural America are needed. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Unhealthy Lifestyles of Rural/Urban Minorities: Alcohol Use Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use

Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural areas. Methods: A telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS), in the years 1995/1997 and 1999/2001. Results: Urban counties led rural counties for moderate and heavy drinking in 1999/2001, and also saw the largest increases in heavy drinking between 1995/1997 and 1999/2001. Binge drinking was nearly as high in remote rural counties with a large town as in urban counties, and increased the most for remote rural counties with a large town. Urban whites were more likely than any other racial/ethnic group to report moderate or heavy drinking, while American Indians in remote rural counties with a large town were the most likely to report binge drinking. Significant increases in heavy and binge drinking were highest for rural residents in the Northeast and Midwest and lowest in the South Census region. Conclusions: Heavy drinking was highest and increased the most in urban counties; however, binge drinking increased the most in remote rural counties with a large town, and heavy and binge drinking increased for rural counties of all types. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Trends in Rural Perinatal Care of American Indians While there have been dramatic improvements in AI/AN maternal and child health since these measures...
National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)

While there have been dramatic improvements in AI/AN maternal and child health since these measures were first recorded in the mid-1950s, significant disparities persist between AI/AN and non-AI/AN populations in the United States. This study (1) examined trends in prenatal care use, low-birthweight rate, and the neonatal and postneonatal mortality rates in rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends in the white populations during the same time period; (2) examined trends in causes of death for rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends to the white population during the same time period; and (3) analyzed trends in our study measures for AI/AN and white populations by Census region, division, and Indian Health Service (IHS) Service Areas. The study used the National Linked Birth Death Data Set at three points in time: 1985-1987, 1989-1991, and 1995-1997, and compared rates of inadequate prenatal care, low birthweight, neonatal and postneonatal death, and causes of death between rural AI/ANs and Caucasians in each of the three time periods, as well as over time. Funded by HRSA’s ORHP.

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Trends in Rural Perinatal Care Little is known about long-term national trends in birth outcomes and use of prenatal care in the...
Changes in U.S. Rural Perinatal Care During the Last Decade

Little is known about long-term national trends in birth outcomes and use of prenatal care in the rural population of the United States, or about intrarural differences in adverse outcome and inadequate prenatal care. In this two-year study, we examined: (1) How have rates of adverse birth outcome and prenatal care among U.S. rural residents changed in the years between 1985-1987 and 1995-1997? and (2) How have adverse birth outcomes and prenatal care changed during these periods among rural residents from racial and ethnic minority groups? We examined data from the Linked Birth Death Data Set (LBDDS), a national compilation of birth certificate data from all 50 states and the District of Columbia. We assessed inter-decade changes in rural/urban and intrarural differences in the rate of low birthweight outcome, neonatal death, postneonatal mortality, and inadequate prenatal care. We also assessed the degree to which observed changes were concentrated in particular types of rural settings or regions. Funded by HRSA’s ORHP.

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Trends in Rural Dentistry This study used secondary data sources such as the Area Resource File, American Dental Association...
Rural Dentistry: Availability, Practice, and Access

This study used secondary data sources such as the Area Resource File, American Dental Association data, and state-level professional licensure data to describe the supply of dental providers in several states, with particular attention to the supply of providers in rural areas. Surveys were administered to rural dentists in California, Maine, Missouri, and Alabama to describe the rural dental provider population in those states with respect to demography, practice characteristics, practice satisfaction, use of dental hygienists, Medicaid and CHIP practices, and attitudes towards the use of alternative sources of dental care such as using medical providers to apply sealants in the pediatric population. The study elucidates, from the dental provider perspective, the barriers to access to dental care for rural residents and what can be done to promote rural dental practice. Funded by HRSA’s ORHP.

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Tort Reform & Obstetrical Access As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of...
Tort Reform and the Obstetrical Access Crisis

As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of this study had modified the existing tort and/or professional liability systems in their states. This project reviewed recent studies of physicians’ obstetrical practices and major changes in tort legislation and regulation. The majority of general and family physicians in the WAMI region no longer provided obstetrical care, while over 80% of the obstetrician/gynecologists in this area still practiced obstetrics. Most rural family physicians in all four states continued to deliver babies. The majority of physicians in these states limited the amount of care they provide to Medicaid patients. All four states adopted tort reforms, yet the cost of malpractice premiums and concerns over liability continued to limit the number of physicians willing to provide obstetrical care.

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The WWAMI Rural Health Workforce This project compiles and presents state-level information about the rural health workforce in the...
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho

This project compiles and presents state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. Information was derived from the American Medical Association Masterfile, the National Sample Survey of Registered Nurses, the Area Resource File, and other sources. This series of policy briefs describes WWAMI rural health workforce challenges and opportunities, workforce numbers, resources, the importance of rural definitions, and tools for workforce policymakers and planners.

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The Workforce Investment Act This 2002-2003 project identified and described the efforts that linked job seekers with the health...
The Workforce Investment Act of 1998: Are States Targeting the Health Workforce?

This 2002-2003 project identified and described the efforts that linked job seekers with the health workforce through Workforce Investment Act of 1998 (WIA) programs throughout the United States. It enumerated the goals and strategies that states and their regional workforce boards were using to develop their health workforce using WIA funding. Funded by HRSA, National Center for Health Workforce Analysis.

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The Workforce Investment Act This 2002-2003 project identified and described the efforts that linked job seekers with the health...
The Workforce Investment Act of 1998: Are States Targeting the Health Workforce?

This 2002-2003 project identified and described the efforts that linked job seekers with the health workforce through Workforce Investment Act of 1998 (WIA) programs throughout the United States. It enumerated the goals and strategies that states and their regional workforce boards were using to develop their health workforce using WIA funding. Funded by HRSA, National Center for Health Workforce Analysis.

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The Walkability Project This study is identifying built environmental correlates of walking in rural towns and evaluating...
Small Town Walkability: Measuring the Effect of the Built Environment

This study is identifying built environmental correlates of walking in rural towns and evaluating the role of low socioeconomic status (SES) and Latino ethnicity on these relationships. By studying 9 rural towns from 3 diverse regions, Washington State, the Northeast, and Texas, with a varying range of socioeconomic and ethnic characteristics, this study is: (1) measuring built environmental correlates of walking among small town residents, using objective and perceived measures of the built environment and self-reported measures of walking; (2) evaluating the degree to which built environmental correlates of walking among rural town residents are influenced by SES and Latino ethnicity; and (3) validating the perceived correlates of walking using accelerometer and global positioning system measures. The study will first involve a survey of 1,800 residents of these towns on physical activity patterns and attributes of their towns that promote or impede walking, and will next recruit a sample of 270 respondents who agree to wear two small devices measuring their physical activity for 7 consecutive days. Objective measures of their physical activity will be compared to self-reported data. This work will lay the foundation for future research on the relationship between various aspects of the rural built environment and health behaviors and, ultimately, intervention trials to help rural towns better structure the built environment to promote walking and healthier life styles among their highest risk residents.

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The Rural Public Health Workforce Rural local health districts are often the only formal public health presence in small remote...
Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)

Rural local health districts are often the only formal public health presence in small remote communities. This study described the people who staff these departments in three western states, compared the per capita supply of public health professionals in rural and urban districts, and explored some of the major challenges faced by rural public health. This series of studies (1999 to 2001) was funded by HRSA, National Center for Health Workforce Analysis.

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The Public Health Workforce As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case...
Defining the Public Health Workforce: Case Studies in MT, NY, TX, GA, NM and CA

As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case study of the staffing needs of local health departments in Montana. The national study describes local and state public health agencies’ staffing needs, with emphasis on nursing and physician staff, in Montana, New York, Texas, Georgia, New Mexico and California. Funded by the New York CHWS, through a contract with HRSA, Bureau of Health Professions.

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The Public Health Workforce As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case...
Defining the Public Health Workforce: Case Studies in MT, NY, TX, GA, NM and CA

As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case study of the staffing needs of local health departments in Montana. The national study describes local and state public health agencies’ staffing needs, with emphasis on nursing and physician staff, in Montana, New York, Texas, Georgia, New Mexico and California. Funded by the New York CHWS, through a contract with HRSA, Bureau of Health Professions.

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The Future of Health Workforce Data and Methods AcademyHealth, with funding from the Robert Wood Johnson Foundation, contracted with the University...
The Future of Health Services Data and Methods: Health Care Workforce Planning

AcademyHealth, with funding from the Robert Wood Johnson Foundation, contracted with the University of Washington Center for Health Workforce Studies to participate in the development of several papers and presentations on ways to improve the research and data infrastructure for health workforce research.

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Survey of Washington Primary Care Physicians, NPs, and PAs The Washington State Office of Financial Management surveyed primary care physicians, nurse...
Washington State Survey of Primary Care Physicians, Nurse Practitioners, and Physician Assistants–Technical Assistance

The Washington State Office of Financial Management surveyed primary care physicians, nurse practitioners, and physician assistants in Washington State to assess access to primary care for Washington’s residents. The WWAMI Center for Health Workforce Studies provided technical assistance to help facilitate the survey. This project was funded by the Washington State Office of Financial Management through a grant from the U.S. Department of Health and Human Services’ Health Resources and Services Administration.

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Surgical Procedures in Rural This report addresses rural/urban differences in surgical practices in commonly performed inpatient...
General and Specialist Surgeon Supply and Inpatient Procedural Content: A National Rural-Urban Study

This report addresses rural/urban differences in surgical practices in commonly performed inpatient surgical procedures that are typically handled by general surgeons. National Inpatient Sample data from rural and urban hospitals in 24 states were used to examine the frequency of general surgical procedures, complications during hospitalizations and predicted resource demand.
Findings indicate that rural hospitals concentrated on relatively common, low complexity procedures that can be handled by general surgeons, especially if they have received additional training in obstetrics/gynecology and orthopedics. Resource demand, length of stay, complication rates and mortality were lower for patients undergoing common procedures in rural hospitals. Rural training tracks for general surgery that provide a high case load for common general surgery, obstetrics/gynecology and orthopedics procedures may help sustain the general surgery workforce in rural areas.

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Surgery in Rural/Urban Hospitals Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were...
Surgical Outcomes of Rural and Urban Hospitals

Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were used in an analysis of readmission rates for four selected conditions by patient residential and hospital location. During the two-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals. No evidence of low-quality care in Washington State rural hospitals was found when investigating readmission rates following common surgeries.

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Supply and Retention of Rural Surgeons Background: General surgeons form a crucial component of the medical workforce in rural areas of...
Distribution and Retention of General Surgeons in Rural Areas of the U.S.

Background: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. Aim: To determine the numbers, characteristics, and distribution of general surgeons currently practicing in the rural United States. Methods: The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their location and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas (RUCAs). Results: Nationally, the number of general surgeons per 100,000 population varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation’s general surgeons were female. General surgeons in the smallest rural areas were more likely than those in urban areas to be male (92.7% versus 88.3%), 50 years of age or older (51.6% versus 42.1%), or international medical graduates (25.2% versus 20.1%). Conclusions: The overall size of the rural general surgical workforce has remained static, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. This project was funded by HRSA’s FORHP, with the publication Thompson et al. 2005 and Final Report #77 as deliverables.

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Success Factors for AI/AN Medical School Applicants This study surveyed those AI/AN students who applied to the University of Washington School of...
An Analysis of Factors that Affect the Acceptance of American Indians and Alaska Natives (AI/ANs) into Medical School Training Programs

This study surveyed those AI/AN students who applied to the University of Washington School of Medicine over two years to identify the supports and barriers they experienced in the application process, the path they have taken if rejected from medical school, and how their medical school rejection (if rejected) may have affected their plans to enter a health profession.

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State Workforce Planning Techn. Assist. (NGA) Through funding by and collaboration with the National Governors Association (NGA), this project...
Health Workforce Planning Technical Assistance to States (NGA)

Through funding by and collaboration with the National Governors Association (NGA), this project involves providing technical assistance to states that are awarded NGA grants to hold one-day health workforce planning meetings with the state’s leading health policy and program stakeholders. Susan Skillman, Deputy Director of the University of Washington Center for Health Workforce Studies, is working with NGA staff to help grantee states plan and carry out health workforce planning meetings, each with goals and objectives determined by the state.
State health workforce planning technical assistance meetings to-date:
Montana (8/13/13)
Washington (9/5/13)
Colorado (1/7/14)
Kentucky (1/17/14)

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State Rural Health Workforce Monograph The uneven distribution of health care providers across rural and urban areas of the United States...
State Rural Health Workforce Monograph

The uneven distribution of health care providers across rural and urban areas of the United States continues to impede access to care for millions of rural residents. This book profiles that workforce with comparisons of the supply of health professionals across the 50 states and within the rural areas of each state. In addition to individual state workforce profiles, the book includes discussion of key policy and methodological issues in workforce analysis. The data and analysis show that the nature and magnitude of rural health workforce problems vary substantially both across states and within them, suggesting the dangers of “one-size-fits-all” policy solutions. This book provides a picture of the rural health workforce that will serve analysts and policy makers well as they search for workable solutions to the problem of inadequate supply of health care providers in rural America. Funded by HRSA’s FORHP.

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Staffing of Rural Hospital ERs All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how...
Physician Staffing of Small Rural Hospital Emergency Departments

All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how rural emergency departments were staffed by physicians and to estimate rural hospital payments for these services. Study data were collected through telephone interviews with hospital administrators or directors of nursing services. Results indicated that 86% of rural hospitals contracted for emergency department coverage and 59% obtained some or all of this service from nonlocal physicians.

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Specialty Care for Rural American Indians Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native...
Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)

Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native (AI/AN) health services is less than half that spent per year on the U.S. civilian population. Many AI/ANs, especially in rural areas, depend on the IHS as their only source of funding for health care. Specialty services may be limited by a low level of contract funding. Aim: To examine access to specialty services among rural AI populations. Methods: A mail survey addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services was sent to primary care providers in rural Indian health clinics in Montana and New Mexico and primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics. Results: Substantial proportions of rural Indian clinic providers in Montana and New Mexico reported fair or poor access to nonemergent specialty services for their patients. Montana’s rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico’s rural Indian and non-Indian providers reported comparable access. Indian clinic providers in most frequently cited financial barriers to specialty care. Indian clinic providers in both states reported better access to several nonphysician services than non-Indian clinic providers. Conclusions: Access to specialty care for rural Indian patients is limited, and is influenced by the organization of care systems and financial constraints. Funded by HRSA’s FORHP.

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Snapshot: RNs in Washington 2001, 2006, 2007, 2008, 2011, 2013, 2014 Demographic and employment characteristics of registered nurses (RNs) in Washington State are...
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics

Demographic and employment characteristics of registered nurses (RNs) in Washington State are described in these snapshots of data from the state health professionals licensing and renewal survey database. Funded by the Washington Center for Nursing through a Department of Health grant.

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Snapshot: Pharmacists in Washington Demographic and employment characteristics of pharmacists in Washington State are described in this...
Pharmacists in Washington: Snapshot of Demographics and Employment Characteristics in 1999

Demographic and employment characteristics of pharmacists in Washington State are described in this snapshot of data from the 1999 state health professionals licensing and renewal survey database. Funded by HRSA, National Center for Health Workforce Analysis.

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2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics Demographic and employment characteristics of licensed practical nurses (LPNs) in Washington State...
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics

Demographic and employment characteristics of licensed practical nurses (LPNs) in Washington State are described in these snapshots of data from analyses of the state health professionals licensing and renewal survey database. Funded by the Washington Center for Nursing through a Department of Health grant.

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Snapshot: ARNPs in Washington 2006, 2007, 2008, 2011, 2013, 2014 The number, geographic distribution, age, and gender of advanced registered nurse practitioners...
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners

The number, geographic distribution, age, and gender of advanced registered nurse practitioners (ARNPs) in Washington State are described in these snapshots of data from the state health professionals licensing and renewal survey database. The reports also show changes in these characteristics since 1999. Funded by the Washington Center for Nursing through a Department of Health grant.

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Rural/Urban Obstetrical Care Quality Washington State vital statistics data from 1984 through 1988 were used to investigate differences...
Quality of Obstetrical Care Provided to Rural Versus Urban Residents

Washington State vital statistics data from 1984 through 1988 were used to investigate differences in the process and outcome of obstetrical care based on the rural/urban locations of the mothers’ residences. This study compared rural and urban obstetrical care in terms of mortality, trimester prenatal care began, adequacy of the number of prenatal visits, and birthweight. Separate analyses (1) differentiated between rural mothers who delivered in rural locations and those that delivered in urban locales and (2) partitioned low and non-low risk women.

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Rural/Urban Generalists This two-year project used Medicare data provided by HCFA to describe the content of practice of...
Who Are the Generalists in Rural and Urban Areas?

This two-year project used Medicare data provided by HCFA to describe the content of practice of physicians in rural and urban areas of Washington State. The population studied included board-certified physicians in the 12 largest ambulatory medical specialties in Washington State who were in active medical practice in 1994 and who provided ambulatory care to at least ten Medicare patients per year during that period. The diagnostic and procedural breadth of rural and urban physicians in all specialties was found to be similar, with the exception of rural general surgeons and obstetrician-gynecologists, who were more likely to care for patients outside their specialty area. Funded by HRSA’s ORHP.

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Rural U.S. Perinatal Health This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth...
Perinatal Health in the Rural United States, 2005

This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth weight, a key indicator of the health of the U.S. population, and adequacy of prenatal care, a critical indicator of access and quality of health care, were explored to discover how they are related to rural or urban location, race, and ethnicity.

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Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...
Factors Associated with Rural-Residing Registered Nurses' Choices to work in Urban Locations and Larger Rural Cities

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

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Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...
Factors Associated with Rural-Residing Registered Nurses' Choices to work in Urban Locations and Larger Rural Cities

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

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Rural RNs in the U.S.: 2000 This study used data from HRSA's 2000 National Sample Survey of Registered Nurses (NSSRN) to...
Characteristics of Rural RNs in the U.S.: Analysis of the 2000 National Sample Survey of RNs

This study used data from HRSA’s 2000 National Sample Survey of Registered Nurses (NSSRN) to compare RNs in urban areas of the United States with nurses in three categories of rural areas. The study examined rural and urban RNs’ demographic characteristics, educational backgrounds and employment characteristics. It also explored whether the characteristics of nurses in more isolated rural areas differ from those in other rural areas, and whether education and employment patterns are consistent across regions of the United States. Funded by HRSA, National Center for Health Workforce Analysis.

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Rural RNs in the U.S.: 2000 This study used data from HRSA's 2000 National Sample Survey of Registered Nurses (NSSRN) to...
Characteristics of Rural RNs in the U.S.: Analysis of the 2000 National Sample Survey of RNs

This study used data from HRSA’s 2000 National Sample Survey of Registered Nurses (NSSRN) to compare RNs in urban areas of the United States with nurses in three categories of rural areas. The study examined rural and urban RNs’ demographic characteristics, educational backgrounds and employment characteristics. It also explored whether the characteristics of nurses in more isolated rural areas differ from those in other rural areas, and whether education and employment patterns are consistent across regions of the United States. Funded by HRSA, National Center for Health Workforce Analysis.

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Rural Pediatric Inpatient Care This study described the distribution of rural practitioners in Washington State who provide...
Pediatric Inpatient Care in Rural Hospitals

This study described the distribution of rural practitioners in Washington State who provide inpatient care to pediatric patients, elucidated the major diagnostic categories for which children are hospitalized in rural versus urban areas, contrasted the roles of pediatricians and family physicians providing pediatric care, and assessed the effectiveness of the system. The major source of data for this study was CHARS, which was linked to information on the training and discipline of the providers who cared for each of the patients in the study. Funded by HRSA’s ORHP.

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Rural Obstetrical Technology This study compared the approach to neonatal care in Wales and Washington State, studying the...
A Comparison of Obstetrical Technology at Rural Hospitals in Washington and Wales

This study compared the approach to neonatal care in Wales and Washington State, studying the extent of perinatal regionalization, the distribution of neonatal technologies, and birthweight-specific neonatal outcomes. In Wales, most District General Hospitals (DGH) had all the neonatal equipment recommended for a maximal neonatal intensive care unit, whether or not the DGH was a designated regional or subregional center. Sophisticated neonatal technology in Washington was concentrated in designated referral hospitals. Almost every Welsh DGH cared for infants weighing less than 1,000 grams at birth, while in Washington State most very-low-birthweight neonates were born in referral centers and the few born elsewhere were transferred immediately after birth. Despite differences in the extent of regionalization, birthweight-specific neonatal mortality rates were similar in the two countries.

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Rural Medicine Textbook This book explores what is known about the content, needs, and special problems of rural health...
FORHP Rural Health Research Center Book and Rural Medicine Textbook

This book explores what is known about the content, needs, and special problems of rural health care. The goal was to advance the knowledge base and describe strategies used by rural health professionals in developing quality of care for rural communities and their residents. The book includes an overview of rural health care, special clinical problems and approaches in rural health care, the organization and management of rural health care, approaches to quality improvement, and education for rural practice.

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Rural Hospital Surgical Capacity This study examined the availability of several elective and urgent surgical procedures at rural...
Surgical Capacity of Rural Washington State Hospitals

This study examined the availability of several elective and urgent surgical procedures at rural hospitals, identified the specialties of rural surgery and anesthesia providers, and determined where rural residents obtained surgical services and how the utilization of services is influenced by the presence of local services. Data were obtained from telephone interviews with hospital administrators, directors of nursing services, and/or operating room charge nurses. Washington State complete hospital discharge data provided the number of selected and aggregate procedures for each hospital by diagnosis and procedure codes, as well as hospital reimbursement for surgical procedures.

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Rural Hospital Project The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through...
Transferability of the Rural Hospital Project

The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through a multifaceted approach to addressing their problems and strengthening health services. Subsequently, the RHP interventions were applied through a Community Health Services Development Model to other rural hospitals throughout the regional Area Health Education Centers (AHECs). This study examined the process of exporting the interventions from a university-based demonstration project to a community-based program disseminated by the AHECs.

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Rural Hospital Linkages Linkage refers to a rural hospital's formal and informal associations with outside entities (e.g.,...
Rural Hospital Linkages in the WAMI Region

Linkage refers to a rural hospital’s formal and informal associations with outside entities (e.g., joint purchasing arrangements and inter-hospital networks). This study (1) provided a descriptive analysis of rural hospital linkages in the WAMI states based on a literature review and key informant interviews, (2) determined how governmental regulations influence such linkages, and (3) performed case studies on two rural health care alliances located in different regions and formed 13 years apart.

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Rural Hospital Governing Boards Part C Background: Little research has been conducted to describe the factors and practices associated...
Characteristics of Rural Hospital Governing Boards. Part C: Which Activities of Small Rural Hospital Boards Are Associated with Success?

Background: Little research has been conducted to describe the factors and practices associated with the effectiveness of rural hospital governing boards. Aim: To identify activities and characteristics of the governing boards of small rural hospitals that are related to hospital success. Methods: We surveyed 89 rural hospital board chairs in Washington, Alaska, and Idaho about how they spent their time and how they were organized. We asked experts familiar with 74 hospitals with less than 100 beds to rate them in several key areas. Results: The eight activities of boards associated with “strong” hospitals included: one or more board retreats per year, annual review of mission and goals, lower percentage of time monitoring budget, use of board committees, clear recruitment plan to attract desirable board members, funds for continuing education of board members, owned or leased ownership, and larger hospital average daily census. In addition, the “strong” hospitals were found to have higher daily census than the “weak” hospitals (higher among hospitals with less than 100 beds). Conclusions: As long as the governance of rural hospitals is in the hands of volunteer boards, researchers and policy makers should assist these boards in identifying the most efficient and effective ways for them to spend their limited time and resources. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part B Background: To provide competent membership, a board member needs knowledge of health care...
Characteristics of Rural Hospital Governing Boards. Part B: An Assessment of the Knowledge of Governing Board Members in Rural Hospitals

Background: To provide competent membership, a board member needs knowledge of health care developments and the organization of the board. Aim: To provide information on the knowledge level of governing board members in hospitals in three northwestern states. Methods: This study included 130 hospitals with individual governing boards in rural areas of Alaska, Idaho, and Washington. As part of a larger survey of all rural hospital board members in these states, we asked board members questions relevant to competent membership on a governing board. This included questions concerning quantifiable aspects of the hospitals, planning, and financial reporting. Results: Knowledge on the part of the board members was strongest in the areas of the role of the governing board, planning, and scope of services. Board members were less able to quantify the capacities and utilization of services at their hospitals. Results were mixed in the area of knowledge of financial management. Length of service on the board and efficient board structures were associated with increased knowledge. Conclusions: While board members were knowledgeable about their roles and the services offered by their hospitals, their knowledge base in certain other crucial areas was limited, underscoring the need for programs that facilitate board member training. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part A Background: Literature about rural health providers has focused largely on physicians, mid-level...
Characteristics of Rural Hospital Governing Boards. Part A: Who Governs Rural Hospitals?

Background: Literature about rural health providers has focused largely on physicians, mid-level providers, and hospitals and their administrators, but little has been written about the boards that govern those hospitals. Aim: To describe the role and composition of rural hospital governing boards. Methods: Hospitals in Washington, Alaska, and Idaho were included in this study. Surveys related to hospital governance were administered to rural hospital board members and board chairpersons of urban and rural hospitals. Results: Board members were typically white males over the age of 50 and retired. They served an average of seven years and most typically brought business and management expertise to their positions. Board members contributed more than a dozen hours per month to board business and attended about 90% of their board and committee meetings. Fewer than one in four rural hospital board chairs indicated his or her board had a formal recruitment program, and fewer than half of the boards spent more than three hours on board member orientation. Board chairs were more likely to rate highly the performance of other community leaders, as well as members of the medical staff. Conclusions: Boards are attracting the service of individuals who are well educated, experienced, and willing to contribute more than a dozen hours a month to their board service. However, small rural boards are not investing enough time and funds in orientation and training. Funded by HRSA’s ORHP.

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Rural Hospital CEO Turnover This study described the tenure, rate of and reasons for turnover of hospital administrators, and...
Administrator Turnover in Rural Hospitals

This study described the tenure, rate of and reasons for turnover of hospital administrators, and tracked the career trajectories of rural hospital administrators. The study was performed in partnership with the WAMI Area Health Education Center and the Washington State Hospital Association. Resumes from all Washington State hospital administrators contrasted the education and professional backgrounds of rural and urban administrators. A survey of all regional rural hospital administrators who left their position during the past three years provided information on hospital characteristics, reasons that they left, effects on the hospital and community, evaluation of their performance, and gaps in training. Questionnaires were sent to a hospital board member in the same community to ascertain why the administrator left, consequences of the departure, and adequacy of the administrator’s performance.

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Rural Hospital Care for Acute Myocardial Infarction: 2000-2001 This project examined whether overall improvements in the quality of care for acute myocardial...
Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?

This project examined whether overall improvements in the quality of care for acute myocardial infarction (AMI) among Medicare patients occurred in both rural and hospital settings. It used the Cooperative Cardiovascular Project Database and a database of measures of clinical performance, and included in the sample those Medicare beneficiaries with an AMI who were directly admitted for AMI care. Funded by HRSA’s ORHP.

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Rural Hospital Anesthesia Services Key to the ability of rural hospitals to maintain a surgery service is the availability of...
The Provision of Anesthesia Services in Rural Hospitals

Key to the ability of rural hospitals to maintain a surgery service is the availability of anesthesia personnel, yet anecdotal evidence indicates that their supply is limited and their salary costs are high. This study surveyed administrators from rural hospitals in Washington and Montana regarding their experience in recruiting and retaining nurse and physician anesthetists. Aspects of anesthesia coverage such as financial arrangements, professionals working at multiple sites, outpatient and inpatient surgery, inter-provider type professional rivalries, and licensure constraints were examined. Funded by HRSA’s ORHP.

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Rural HIT Workforce Needs The goal of this study was to improve understanding of health information technology (HIT)...
Health Information Technology (HIT) Workforce Needs in Rural America

The goal of this study was to improve understanding of health information technology (HIT) workforce needs and constraints in rural primary care settings. This study determined rural primary care practices’ current and projected level of electronic health record (EHR) and health information technology (HIT) adoption and estimate demand for workers with HIT skills. This study surveyed a stratified sample (large and small rural areas) of approximately 1,600 rural primary care practices across the U.S. The questionnaire assessed EHR and HIT implementation at the facility level; their relative need for different components of the HIT workforce; and whether they train and develop HIT staff from within, hire new staff, employ consultants, and/or join forces with other institutions to fill these workforce needs. We included questions about the institutions’ current HIT workforce, expected future demand, education and training resources available to the institution and its staff, and other workforce-related factors that support or impede the practices’ implementation and use of HIT. Our descriptive analyses produced national rural and sub-rural estimates of findings. The study identified relationships between specific practice attributes and HIT workforce variables.
This study was funded by HRSA’s Office of Rural Health Policy.

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Rural Health Policy Briefs University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to...
Policy Briefs on Rural Health Workforce Issues

University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to inform policymakers about potential solutions to health workforce crises in rural America. The briefs address rural health workforce issues in general surgery, nursing, primary care, and dentistry.

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Rural FLEX Program In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of...
National Rural Hospital Flexibility Program Tracking Project

In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.

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Rural Family Practice Residency Programs Chartbook This chartbook makes previously unreported information from our national survey of 453 FP residency...
Chartbook of Family Practice Graduate Medical Education Programs in Rural America

This chartbook makes previously unreported information from our national survey of 453 FP residency directors available to medical educators and policy makers. As part of this survey, programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas (RUCAs), the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. The chartbook presents national, regional, state, and division findings, presented by type of geography (i.e., isolated small rural, small rural, large rural, and urban), type of rural training experience (i.e., model family practice clinic, block rotations, rural training tracks, and continuity clinics), and other residency characteristics. Funded by HRSA’s ORHP.

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Rural Family Planning Services Considerable controversy exists about the types of family planning services that should be...
Accessibility of Family Planning Services to Rural Residents

Considerable controversy exists about the types of family planning services that should be available in rural areas. This study constructed an inventory of family planning services available in rural Idaho, determined the factors associated with observed variations in the range of available services, and examined the policy implications of the findings. A questionnaire was sent to physicians who were the potential providers of such services to determine service volumes and access issues.

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Rural Family Medicine Residency Survey Follow-Up This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in...
Rural Family Medicine Residency Training Follow-Up Survey Regarding Amount and Types of Rural Training Experiences

This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in rural areas of the United States. In 2000 we conducted a national survey of all family medicine residency training programs in the nation to identify the type and extent of residency training that actually took place in rural locations. This study administered a follow-up mail survey to all family medicine residency training programs (about 440) using an instrument that was modified slightly to add a few key questions. This allowed us to examine changes since 2000 in the number of programs located in rural places, the nature of these programs, funding sources and staff configurations, as well as the amount of time that training takes place in federally funded health centers and other types of facilities.

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Rural Emergency Medical Services This study retrieved data on every vehicular injury accident occurring in Okanogan County,...
Regionalization of Rural Emergency Medical Services (EMS)

This study retrieved data on every vehicular injury accident occurring in Okanogan County, Washington, in 1990. Information was collected on location of accident, type and severity of injury, initial pre-hospital response, initial transportation, involvement of local health care system, transfer to facility outside county, patient outcomes, and demographics. The study included (1) a description of the type and nature of crashes and injuries and the involvement of local and distant components of the EMS, (2) an examination of the extent to which the existing rural EMS is regionalized, and (3) policy-oriented recommendations.

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Rural Definitions We published an article entitled "Rural Definitions for Health Policy and Research" in the American...
Description of Differences Between Seclected Rural-Urban Taxonomies

We published an article entitled “Rural Definitions for Health Policy and Research” in the American Journal of Public Health in which we describe and compare various rural and urban taxonomies that were in use, describing their characteristics, strengths, and weaknesses depending on the purpose at hand.

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Rural Definition Reclassification This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area...
Rural Definition Reclassification Project

This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area (RUCA) codes.

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Rural Capacity for Family Physicians This paper addressed the ability of smaller and underserved rural communities to financially...
How Many Physicians Can a Rural Town Support?

This paper addressed the ability of smaller and underserved rural communities to financially support needed physicians. We used Washington State data to test the feasibility of constructing physician income potential models. The total spending for primary care physicians was estimated using age-sex-poverty status coefficients from the National Medical Expenditure Survey, supplemented by unique Part B Medicare data on the proportion of rural physician revenue from non-office based services. Community size and the distance to other cities and towns were crucial determinants of market share and thus the capacity of small towns to attract and support primary care practices. The distribution of physicians among towns followed predicted economic potential. That potential varied dramatically even among towns with similar populations due to the pull of competing locations for primary care. Surprisingly, the types of rural communities most likely to have fewer physicians than suggested by the projected potential were not small isolated towns, but larger communities with above-average population growth, closer proximity to metropolitan areas and somewhat lower average family incomes. Strategies such as the National Health Service Corps use a one-time “signing bonus” to overcome physicians’ initial reluctance to locate in an underserved area. An alternative approach is to address long-term income disadvantages by offering continuous subsidies such as the enhanced Medicare payments for certified Rural Health Clinics or the 10% Medicare supplemental payments for care provided in a HPSA.
This study was funded by HRSA’s Office of Rural Health Policy.

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Rural C- Sections This project provided information on how physician training, community specialty mix and other...
Rural C-Sections and Family Physicians

This project provided information on how physician training, community specialty mix and other factors are related to the provision of c-sections in rural communities. We examined the percentage of the c-sections performed on rural service area residents that were done in small rural hospitals, whether family physicians did most of these procedures in rural hospitals where there are no obstetricians, their competence in performing c-sections, and factors associated with their performance of this procedure. Data were obtained through Computerized Hospital Discharge Database (CHARS) inpatient hospital abstracts supplemented by a telephone survey of all Washington State rural hospitals and a mail survey of rural physicians. Funded by HRSA’s ORHP.

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RUCA Development & Description The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and...
RUCA Development Project: Demographic Description and Frontier Enhancement

The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and with support from, HRSA’s ORHP and the Department of Agriculture. The RUCAs are a census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area (UA) and Urban Place (UP) definitions with commuting information to characterize the nation’s Census tracts regarding their rural and urban status and relationships. The codes are based on whether a Census tract is located in a UA or UP and on the destination of its largest and second largest commuting flows. This project (1) produced and described the base 1998 demography of the RUCA code areas, (2) created quality state maps of the RUCA codes, and (3) has made this information and the codes easily available on the Web. The demographic description of the RUCA codes involved standard cross-tabulation analysis of the code areas nationally, regionally, and by state. Technical notes and maps are posted at www.depts.washington.edu/uwruca”>UW RUCA.

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Retention of NHSC Recipients This study examined the retention and distribution of the 6,300 NHSC allopathic physician...
National Health Service Corps Scholarship Recipient Retention Study

This study examined the retention and distribution of the 6,300 NHSC allopathic physician scholarship recipients graduating from medical schools for the years 1975 through 1983. The roster of these scholarship recipients was linked with American Medical Association data to provide information on their location, specialty, and practice status. Recipients were examined in terms of their propensity to remain in their original ZIP code, county, state, and rural/urban status location. In addition, their locational patterns were compared to other graduates. Recipients’ specialty, type of practice, and NHSC length of obligation were also evaluated.

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Retail Pharmacies in Washington This study surveyed retail pharmacies in Washington to estimate the demand for pharmacists,...
Retail Pharmacies in Washington: Results of a 2003 Workforce Demand Survey

This study surveyed retail pharmacies in Washington to estimate the demand for pharmacists, pharmacy technicians and administrative/clerical staff in the state. The survey also provided data to describe the impact of implementation of the Health Insurance Portability and Accountability Act (HIPAA) on retail pharmacies. Funded by HRSA, National Center for Health Workforce Analysis, through a Congressional Appropriation to the UW CHWS.

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Recruitment of Rural Women Physicians This study examined differences in the factors female and male generalist physicians considered...
Best Strategies for Recruiting Women Physicians to Rural Practice

This study examined differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identified the practice arrangements that successfully recruited female generalist physicians to rural areas. We mailed questionnaires to generalist physicians recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Compared to men, recruited women were younger, less likely to be married, had fewer children, and worked fewer hours. Women were more likely than men to have been influenced by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of child care, as well as the interpersonal aspects of recruitment. Commonly reported themes reflected the desire for flexibility regarding family issues and the value placed on honesty during recruitment. Men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. The most common methods for obtaining information about practice opportunities were personal networking, prior training experience, recruiters, and outreach by medical practices. This study concluded that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues if they want to achieve a gender-balanced physician workforce. Funded by HRSA’s ORHP.

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Recruiting American Indians/Alaska Natives into Medicine Understanding the factors that support recruitment and retention of American Indian and Alaska...
Factors that Promote the Recruitment of American Indians and Alaska Natives into (AI/ANs) Medicine

Understanding the factors that support recruitment and retention of American Indian and Alaska Native (AI/AN) health professionals is crucial in increasing the supply of health professionals most likely to serve the AI/AN population. To that end, project investigators have conducted a study to identify the factors that promote the recruitment and retention of AI/ANs into medicine. The study interviewed AI/AN medical students enrolled at the University of Washington. Funded by HRSA, National Center for Health Workforce Analysis.

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Radiation Therapy in Rural U.S. This study used cancer registry data from 10 U.S. states to examine which rural cancer patients...
Use of Recommended Radiation Therapy in the Rural U.S.

This study used cancer registry data from 10 U.S. states to examine which rural cancer patients received recommended radiation therapy and what factors influenced receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service location and cancer support program development. Funded by HRSA’s ORHP.

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Quality of Rural Perinatal Care The equitable provision of high-quality obstetric care is a major priority of our health care...
The Process and Quality of Rural Perinatal Care: A National Study

The equitable provision of high-quality obstetric care is a major priority of our health care system, and nowhere is access to such care more threatened than in rural areas. This project determined whether rural mothers receive less care and experience worse outcomes than their urban counterparts, whether racial and ethnic minorities living in rural areas experience different outcomes than their counterparts, and what other factors are associated with less care and poorer outcomes. Data were compiled from the National Center for Health Statistics’ Linked Birth/Death set and the Bureau of Health Professions’ Area Resource File. Measures of process of care included late or no prenatal care, lack of care in the first trimester, and inadequate care as measured by the Kotelchuck Index. Outcome measures included infant mortality and the percentage of children born at low and very low birthweight. This study also compared birth outcomes and process of care for minorities across rural areas and with their urban counterparts. Funded by HRSA’s ORHP.

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Prostate Cancer Treatment in Rural This research used cancer registry data from 10 states to examine the degree to which rural...
Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?

This research used cancer registry data from 10 states to examine the degree to which rural residents diagnosed with early-stage prostate cancer access the full range of surveillance, surgical, and radiation treatment options. Study findings informed cancer centers, advocacy groups, rural program planners, and policymakers about services and programs needed to ensure that rural prostate cancer patients can choose from among all treatment options.

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Programs Producing Rural Physicians This national study used longitudinal data on medical school specialty and practice location choice...
Which Training Programs Produce Rural Physicians? A National Health Workforce Study

This national study used longitudinal data on medical school specialty and practice location choice to determine the extent to which the nation’s medical schools and residency programs varied in their production of rural physicians. This facilitated the identification of medical school and residency program characteristics associated with the highest yield of rural physicians. Funded by HRSA’s ORHP.

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Problem Drinking Among Rural Veterans This study will use national data to measure recent trends in problem drinking among VA-eligible...
Problem Drinking: Trends Among Rural Veterans–A National Study

This study will use national data to measure recent trends in problem drinking among VA-eligible adults in rural and urban locations and couple these data with the locations of VA services and substance abuse treatment facilities to identify rural locations where alcohol treatment services are limited. This project is funded by the Veterans Administration Office of Rural Health, through a contract with the northwest Portland, Oregon, Veterans Affairs Medical Center.

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Primary Care Trends This project critically reviewed the recent waning of primary care and its implications for rural...
Primary Care at a Crossroads Project

This project critically reviewed the recent waning of primary care and its implications for rural populations. The paper chronicled historical changes and trends, put these changes in the larger health care system context, and concluded with a set of policy recommendations that detail options available to policy makers and leaders of the nation’s medical educational establishment.

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Practice Locations of Women Physicians While women are becoming an increasingly large percentage of the graduates of medical schools and...
The Rural/Urban Practice Location Patterns of Women Medical School Graduates

While women are becoming an increasingly large percentage of the graduates of medical schools and of the generalist specialties in particular, they are much less likely to locate their practices in rural towns. If this trend were to persist, implications for access to care in rural areas would be substantial. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future. The study first examined national physician location patterns by medical school graduation cohort per gender differences. The second phase dealt with the production of female generalist physicians by medical schools. Funded by HRSA’s ORHP.

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Policy Activities of AMCC The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives...
Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)

The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives of state government responsible for the delivery of health care to women and children. The major objective of AMCC is to improve access to obstetrical care for socially vulnerable women. The committee successfully served as a forum in which to resolve administrative problems arising between private obstetrical providers and the state’s Medicaid program and was influential in persuading the state legislature to increase Medicaid eligibility, raise provider reimbursements, and improve social services to pregnant women.

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Physician Residency Rural Training The supply of rural physicians is in part determined by the number of family physicians who receive...
Physician Residency Rural Training Baseline Study

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA’s ORHP.

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Physician Residency Rural Training The supply of rural physicians is in part determined by the number of family physicians who receive...
Physician Residency Rural Training Baseline Study

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA’s ORHP.

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Physician Assistant Workforce Trends This study described the historical development of the physician assistant (PA) profession since...
Historical Trends in Physician Assistant Education and their Contribution to Primary Health Care for Rural and Underserved Populations in the U.S.

This study described the historical development of the physician assistant (PA) profession since 1967, with special emphasis on the demography of the PA population, the PA regulatory environment, the evolution of specialty roles, the emergence of practice location patterns, and the contribution by PAs to primary care for rural and underserved populations. The study used data from the American Academy of Physician Assistants, supplemented with data from secondary data sources such as the Area Resource File and an extensive review of the health services literature on PAs. Funded by HRSA, National Center for Health Workforce Analysis.

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Physician Assistant Productivity This 2000 study described the range of productivity in various practice settings as reported by a...
National Estimates of Physician Assistant Productivity

This 2000 study described the range of productivity in various practice settings as reported by a nationally representative sample of physician assistants (PAs) and determined the accuracy of counts of PAs, rather than FTEs, when estimating generalist shortage areas. Funded by HRSA, National Center for Health Workforce Analysis.

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Physician Access for Rural Elderly Patients in rural areas may utilize less medical care than urban patients because of differences...
Access to Physician Care for the Rural Medicare Elderly

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA’s ORHP.

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Physician Access for Rural Elderly Patients in rural areas may utilize less medical care than urban patients because of differences...
Access to Physician Care for the Rural Medicare Elderly

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA’s ORHP.

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Perinatal Technology in Rural Washington One of the major issues confronting rural health care providers is the problem of acquiring complex...
Diffusion of New Perinatal Technology into Rural Areas of Washington State

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

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Perinatal Technology in Rural Washington One of the major issues confronting rural health care providers is the problem of acquiring complex...
Diffusion of New Perinatal Technology into Rural Areas of Washington State

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

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PAs, NPs and CNMs: Changing Scope of Practice This case study in Oregon, part of a nationwide project led by the New York CHWS, investigated the...
The Impact of the Changing Scope of Practice of Physician Assistants, Nurse Practitioners, and Certified Nurse-Midwives on the Supply of Practitioners and Access to Care: Oregon Case Study

This case study in Oregon, part of a nationwide project led by the New York CHWS, investigated the nature and effects on providers’ supply and access to care of changes in nurse practitioners’, certified nurse midwives’, and physician assistants’ scope of practice between 1992 and 2000. Using data from interviews and secondary sources, the UW CHWS’ contribtution to the project traced the emergence and establishment of NP, CNM, and PA professions in Oregon, the history and content of laws governing their practice, and the relationship of scope of practice to provider supply and delivery of care to underserved populations. Funded by the New York CHWS, through a contract with HRSA, Bureau of Health Professions.

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PAs and NPs in Rural Washington Quantified estimates of the total contribution of nurse practitioners (NPs) and physician...
The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State

Quantified estimates of the total contribution of nurse practitioners (NPs) and physician assistants (PAs) to primary care made by these non-physician clinicians (NPCs) are rare. This study used productivity data from the NPC and physician populations in Washington State to assess the contribution to generalist care made by NPCs, the role of NPCs in rural and underserved areas, and the role of women NPCs in the female provider population. Data on demography, medical specialty, place of practice and outpatient visits from license renewal surveys were used to estimate the productivity of generalist physicians and generalist NPCs. Head counts of physicians, NPs and PAs were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate comparisons and estimation of total contribution to care made by each provider type. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). Overall, generalist NPCs made up 23.4% of the generalist provider population and performed about 21.0% of the generalist outpatient visits in Washington State. NPC contribution was higher in rural areas of the state, about 24.7% of all generalist visits, and a bit lower in urban parts of the state, about 20.1% of generalist visits. In rural areas, female physicians provided 49.3% of the visits provided by female providers; female NPCs provided the remaining 50.3%. In urban areas, female physicians provided about 63.5% of the generalist care provided by women and female NPCs provided 46.5%. NPCs made similar contributions to total care in rural Health Professional Shortage Areas compared to rural non-shortage areas, though PAs appeared to contribute somewhat more care in HSAs with severe shortages of providers. NPs and PAs provided over 20% of the generalist outpatient visits in Washington State. Accurate estimates of available generalist care must take into account the contribution of NPs and PAs. Funded by HRSA’s ORHP and BHPr.

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Pacific Islands Continuing Clinical Education Program The Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington...
Pacific Islands Continuing Clinical Education Program (PICCEP)

The Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington (2000-2004) provided continuing education to health professionals throughout the U.S.-associated jurisdictions in the Pacific. Based in Seattle, the University of Washington team worked in close association with other institutions to evaluate and meet continuing clinical education needs in American Samoa, Commonwealth of the Northern Marianas, Federated States of Micronesia, Guam, Republic of the Marshall Islands and the Republic of Palau. The program was funded by the U.S. Health Resources and Services Administration (HRSA) through the Bureau of Health Professions (BHPr) and the Bureau of Primary Health Care (BPHC).

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PA Students Entering Primary Care Purpose: While the number of physician assistants (PAs) participating in the primary care...
Characteristics of Physician Assistant Students Planning to Work in Primary Care

Purpose: While the number of physician assistants (PAs) participating in the primary care workforce continues to rise, the proportion of PAs practicing in primary care rather than other specialties has decreased. The purpose of this study was to identify the characteristics of matriculating PA students planning to enter primary care specialties and compare them with students planning on entering other specialties.
Methods: Data from the Physician Assistant Education Association Matriculating Student Survey (MSS) from 2013 and 2014 were analyzed. In a series of bivariate analyses, demographic characteristics, educational backgrounds, clinical experiences, and practice expectations of students intending to enter primary care practice were compared with those of their counterparts who did not intend to enter primary care. Logistic regression was used to assess the overall importance of demographic, background, and practice expectations variables on practice intentions.
Results: A total of 9283 students responded to the MSS from 2013 and 2014. More than half (58.3%) stated an intention to practice in primary care upon graduation. Those students were more likely than their counterparts to be married, to be Hispanic or Asian, and to have participated in community service prior to starting PA training. They were also less likely to view high income as essential to their careers and more likely to view practicing in rural or underserved areas favorably.
Conclusions: The findings of this study could be used to identify student characteristics associated with an interest in primary care and could contribute to more successful student recruitment and PA curriculum design, especially for PA training programs with a mission focused on producing primary care PAs.
This study resulted in a published paper in the Journal of Physician Assistant Education and a 2-page policy brief, both can be found in publications section of our website.

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Oral Health in Rural This study determined whether shortages of dentists in rural areas of the United States are...
Dentist Supply, Access to Dental Care, and Oral Health Among Rural and Urban Residents: A National Study

This study determined whether shortages of dentists in rural areas of the United States are associated with impaired access to dental care and a higher prevalence of dental disease. Using detailed dentist supply data from the American Dental Association Dentist Masterfile and recent survey data from the nationally-representative Behavioral Risk Factor Surveillance System, we characterized dentist supply-oral health relationships by overall rural vs. urban location and a four-level, rural-urban grouping for the nation and individual states.

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Obstetrical Access in Washington A survey of all potential providers of obstetrical care in Washington State was conducted in 1989,...
Obstetrical Access in Washington State

A survey of all potential providers of obstetrical care in Washington State was conducted in 1989, and results were compared to an earlier survey to assess the extent to which obstetrical access had changed. Although the massive exodus of family physicians from obstetrical practice appeared to have slowed during the follow-up period, there was still substantial net attrition among this group of providers. By contrast, the supply of obstetricians and midwives seemed to be stable. Despite the greater obstetrical participation rate of rural practitioners, members of this group were also quitting obstetrics faster than they could be replaced.

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Nurse Practitioners in Washington This 2003 survey of nurse practitioners examined how many have been educated in-state, how many...
Demographics, Education, and Practice Characteristics of Nurse Practitioners in Washington

This 2003 survey of nurse practitioners examined how many have been educated in-state, how many work full versus part time, the extent to which they provide care to underserved populations, their use of newly acquired expanded drug authority, and other characteristics of their clinical practices. Funded by HRSA National Center for Health Workforce Analysis, through Congressional Appropriation to the UW CHWS.

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NHSC Evaluation A major impediment to access to care is the shortage of primary care physicians in rural locations...
National Health Service Corps Evaluation

A major impediment to access to care is the shortage of primary care physicians in rural locations and inner cities. This extension of an earlier study evaluated the National Health Service Corps (NHSC) scholarship program through a mail survey with phone encouragement of NHSC scholarship recipients who graduated from medical school during 1975-83. The study examined their retention experience, locational career patterns, demographic and practice characteristics, and service in rural sites. Funded by HRSA’s ORHP.

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National PA Study, 1996 The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national...
National Study of Physician Assistants

The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national survey of a random sample of physician assistants (PAs). The RHRC completed a follow-up survey of all the graduates of the University of Washington’s MEDEX Northwest PA program. The follow-up study, in which North Dakota Center for Rural Health Services staff took the lead, examined differences in rural and urban PA content of practice, satisfaction, practice type, practice characteristics, and demographic characteristics. Geographical and chronological career patterns of the PAs were investigated, as well as issues related to prescriptive authority and professional autonomy.

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National EMS Workforce Emergency medical technicians (EMTs) and paramedics are a critical component of any community's...
EMS Workforce for the 21st Century: A National Assessment

Emergency medical technicians (EMTs) and paramedics are a critical component of any community’s Emergency Medical Services (EMS) system. Assuring the continued viability of the prehospital EMS workforce is a key concern for many local, state, federal, and tribal EMS agencies, as well as national EMS organizations. As a first step in systematically addressing the issue, the National Highway Traffic Safety Administration, in partnership with the Health Resources and Services Administration’s (HRSA) Emergency Medical Services for Children program, supported a research project led by the Center for the Health Professions and School of Nursing at the University of California San Francisco with assistance from the Center for Health Workforce Studies at the University of Washington. The intent of this research was to provide guidance to the national EMS community in ensuring a viable EMS workforce for the future. The major objective of this research was to address issues relevant to the process of workforce planning. Research questions addressed the following: (1) Will the EMS workforce be of adequate size and composition to meet the needs of the U.S. population in the future? (2) How can potential workers be attracted to and encouraged to stay in the field of EMS? (3) How can adequate EMS workforce resources be available across all populations and geographic areas? (4) Do we have the data and information needed to address the future demand for and supply of EMTs and paramedics in the United States? What information is lacking and how might it be obtained? To research these questions, project staff used a variety of qualitative and quantitative approaches, including a critical review of EMS workforce literature, analysis of primary and secondary data, and interviews with experts in the field. Expert guidance for the project was provided by a steering committee and formal meetings with representatives from national EMS stakeholder organizations.

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Montana Physician Workforce This study offered data on the size, distribution, demographics, specialties and education history...
Montana Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Montana State’s physician workforce first conducted in 2014 and updated in 2016.

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Montana Physician Supply 2009 The Center for Health Workforce Studies provided the University of Washington School of Medicine...
Montana Physician Supply 2009

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Montana with analyses to inform their discussions about whether expansion of and/or modification to the medical school would alleviate future physician shortages in Montana.

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Middle Skilled Allied Health Occupations Bianca Frogner and Sue Skillman were commissioned in 2015 by an expert committee convened by The...
Pathways to Middle Skilled Allied Health Care Occupations

Bianca Frogner and Sue Skillman were commissioned in 2015 by an expert committee convened by The National Academies, acting for the National Research Council and the National Academy of Engineering, to prepare a paper examining the education and training pathways to middle skilled jobs in the health care field. This paper discusses the current supply of middle skilled jobs and the projected demand for these jobs, the policy and demographic context in which these jobs are demanded, and the education and training paths to enter these jobs and on which to build a long-term career. In this paper, we discuss the opportunities and challenges to identifying career pathways to middle skilled jobs in health care. The focus of this paper is on the set of health care jobs that have a pre-baccalaureate (i.e., less than a four-year degree) entry-level requirement.

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Mental Health Workforce in Washington This project analyzed 1999 Washington State licensing and survey data on the distribution and level...
Modeling the Mental Health Workforce in Washington State: Using Licensing Data to Examine Provider Supply

This project analyzed 1999 Washington State licensing and survey data on the distribution and level of productivity of seven types of mental health providers–psychiatrists, psychologists, certified social workers, mental health counselors, marriage and family counselors, registered counselors, and hypnotherapists–in the 125 Washington Health Service Areas. It used this licensing data to develop two models (one that estimates the actual number of visits and one that adjusts the supply of visits for a reasonable workload) for estimating the supply of mental health visits by both psychiatrists and other mental health providers. Using data from the U.S. Census and the National Comorbidity Survey, the project team then estimated required psychiatric visits in Washington State and its six geographic subareas, and compared this to the available visits to identify areas with gaps in psychiatric services. Funded by HRSA, National Center for Health Workforce Analysis.

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Medicare Bonus Payments in HPSAs Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat...
Medicare Bonus Payments for Physician Care in HPSAs

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in areas where there is a federally designated shortage of generalist physicians. This study examined the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program using a retrospective cohort design utilizing 1998 Medicare Part B data. Physician specialty was determined through American Medical Association Masterfile data. Rural status was determined by linking this ZIP code to its Rural-Urban Commuting Area Code (RUCA). There were 39,780 providers in the study cohort: 24.9% generalists, 53.5% medical and surgical specialists, and 21.6% nonphysician providers. Over $4 million in bonus payments were made to providers in the Health Professional Service Area (HPSA) sites, with a median overall payment of $173. Specialists and urban providers received 58% and 14% of the bonus reimbursements respectively. Nearly a third of the potential bonus payments ($2 million) were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites. Many providers who should have claimed the bonus did not, and many who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers as well as a system that prospectively determines provider eligibility. Funded by HRSA’s ORHP.

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Medical Student Debt This project examined the collision between rising debt and stagnant or falling primary care...
Student Debt and the Decline in Primary Care: Can Medical School Graduates Still Afford to Become Primary Care Doctors?

This project examined the collision between rising debt and stagnant or falling primary care salaries. It tested the hypothesis that the United States may be near the point at which students with large amounts of educational debt are unable to rationally choose to pursue primary care. The study used secondary analysis of two data sources to test this hypothesis: the Medical School Graduation Questionnaire (GQ) administered annually by the American Association of Medical Colleges (AAMC) to senior medical students, and the annual salary surveys of the MGMA. We examined the impact of debt for important sub-groups of the medical student population: underserved minorities, rural students, women, and differences across regions and public versus private medical schools. Funded by HRSA, National Center for Health Workforce Analysis.

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Medical Education and Rural Practice Review This literature review critically examined the research literature related to physician...
Review of the Literature on Medical Education Programs Promoting Rural Practice Location

This literature review critically examined the research literature related to physician undergraduate and graduate medical education and rural practice location. While topics related to rural location choices such as federal and state programs and recruitment and retention were touched upon, the emphasis of the review was on the educational programs themselves. The main objective of the review was to determine what we currently know and what gaps in the literature need to be addressed in order to develop sound public policy. Funded by HRSA’s ORHP.

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Medicaid Primary Care Payment in Washington Enhanced payments for primary care services provided to Medicaid patients in 2013 and 2014,...
The Impact of Medicaid Primary Care Payment Increases in Washington State

Enhanced payments for primary care services provided to Medicaid patients in 2013 and 2014, authorized by the federal Patient Protection and Affordable Care Act (ACA) of 2010, expire in 2015. This study assessed how the Medicaid payment increase affected primary care providers’ willingness to provide care for Medicaid patients in Washington State, how providers may respond if reimbursement rates revert to pre-2013 levels, and which strategies encourage providers to see Medicaid patients.

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MEDEX PA Study, 1994 This project, performed in partnership with MEDEX Northwest in the School of Public Health,...
MEDEX Northwest Physician Assistant Study

This project, performed in partnership with MEDEX Northwest in the School of Public Health, examined the locational choices and role of physician assistants (PAs) in the WAMI states, explored the use of PAs as physician extenders, and described the evolution of PA training and function over the past two decades. We surveyed all MEDEX graduates to identify factors that predict selection of and retention in rural locations. Results of this study improved the ability of training programs to select trainees likely to pursue successful careers in underserved rural areas and identified the kinds of professional environments conducive to attracting and retaining mid-level health care providers.

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MD Views of Rural Hospital Closures This project surveyed the physicians of rural towns whose sole small general hospitals closed...
Physician Perceptions of the Closing of their Small Rural Hospitals

This project surveyed the physicians of rural towns whose sole small general hospitals closed between 1980 and 1988. All locatable physicians who were practicing in the hospital closure towns at the time of the closures were surveyed with a questionnaire similar to that employed in a parallel survey of hospital closure town mayors. The study concentrated on physician perceptions of the reasons the hospitals closed, the consequences of the hospital closures, and the role the physician played in the closure process. Government reimbursement policies and poor hospital management were cited as principal reasons for hospital closures.

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Mayor Views of Rural Hospital Closures This project involved a survey of 130 mayors of rural towns whose sole small general hospitals...
Mayor Perceptions of the Closing of their Small Rural Hospitals

This project involved a survey of 130 mayors of rural towns whose sole small general hospitals closed between 1980 and 1988. Mayors attributed the closure of their hospitals primarily to government reimbursement policies, poor hospital management, and lack of physicians. They reported that they had little warning that their hospitals were in imminent danger of closing. Well over three-fourths of the mayors felt that access to medical care and health status had deteriorated in their community after hospital closure, and over 90% indicated that the hospital closure had substantially impaired the community’s economy.

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Maine physicians, NPs and PAs, 2014 This Brief offers data on the number and distribution of Maine's licensed physicians, nurse...
Maine's Physician, Nurse Practitioner and Physician Assistant Workforce in 2014

This Brief offers data on the number and distribution of Maine’s licensed physicians, nurse practitioners and physician assistants in 2014. Additional analyses detail the demographics, specialties and education history (medical school and residency state) of Maine’s practicing physician workforce. Analyses used data from Maine’s health professions licensure boards, and the American Medical Association Physician Masterfile.

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Maine physicians, NPs and PAs, 2014 This Brief offers data on the number and distribution of Maine's licensed physicians, nurse...
Maine's Physician, Nurse Practitioner and Physician Assistant Workforce in 2014

This Brief offers data on the number and distribution of Maine’s licensed physicians, nurse practitioners and physician assistants in 2014. Additional analyses detail the demographics, specialties and education history (medical school and residency state) of Maine’s practicing physician workforce. Analyses used data from Maine’s health professions licensure boards, and the American Medical Association Physician Masterfile.

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Low-Risk Obstetric Care This study, which was predominantly funded by AHCPR but was also supported through the HRSA's ORHP,...
Low-Risk Obstetric Care Resource Use

This study, which was predominantly funded by AHCPR but was also supported through the HRSA’s ORHP, was part of a large multifaceted project that examined low-risk obstetric care in Washington State through surveying obstetric providers and abstracting detailed information about their patients. This study used the provider as the unit of analysis. Differences in resource use (e.g., visits, tests, and procedures) between rural and urban obstetricians and between rural and urban family physicians were examined in detail.

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Long-Term Care Paraprofessionals As part of a larger national study (led by the New York CHWS), this study examined the extent to...
The Direct-Care Paraprofessinal Workforce Providing Long-Term Care Services in the U.S.: Wyoming Case Study

As part of a larger national study (led by the New York CHWS), this study examined the extent to which policy makers in Wyoming have adequate data on certified nurse aides, home health aides, and other paraprofessional long-term care workers to address the critical issues they face. Information was collected via interviews with key players at the state, local and institutional level. Funded by the NY CHWS, through a contract with HRSA, Bureau of Health Professions.

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Location of PA Practices Despite the need for generalist care providers in rural areas experiencing shortages of generalist...
Physician Assistant Location and Geographic Trajectories: A National Study

Despite the need for generalist care providers in rural areas experiencing shortages of generalist physicians, the percentage of physician assistants (PAs) that practice in small towns has been decreasing. This study examined PA rural and urban location behavior and their geographic trajectories over time based on national PA data collected in an earlier study. Data from sources such as the Area Resource File were used to characterize the areas where PAs were located. Factors such as PA demography, educational program type and location, preceptorship location, and previous health care provider status were examined. As the American health care delivery system changes, with workforce policies that focus more sharply on generalist care, the need to better understand PA practices is crucial. Funded by HRSA’s ORHP.

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International Medical Graduates: Sources and Distribution International medical graduates (IMGs--physicians educated in medical schools other than in the...
The Sources and Distribution of International Medical Graduates (IMGs)

International medical graduates (IMGs–physicians educated in medical schools other than in the United States and Canada) account for nearly 25% of the nation’s practicing physicians. The UW CHWS has conducted a series of research studies about the sources and distribution of IMGs. Funded by HRSA, National Center for Health Workforce Analysis.

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International Medical Graduates' Characteristics Over Time This study of the characteristics of international medical graduates (IMGs) over time examined...
International Medical Graduates: Changes in Characteristics Over Time

This study of the characteristics of international medical graduates (IMGs) over time examined changes in the source countries for IMG education, distribution across the country, demographics of IMGs, and the kinds of medical practices they chose. Funded through a contract with HRSA, Bureau of Health Professions, National Center for Health Workforce Analysis.

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Impact of UW School of Medicine on Washington Physician Supply The Center for Health Workforce Studies provided the University of Washington School of Medicine...
Impact of the University of Washington School of Medicine on Physician Supply in Washington State

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Washington with analyses to inform their discussions of whether expansion of the medical school would alleviate future physician shortages in eastern Washington.

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Impact of Malpractice We studied all family physicians (470) who purchased obstetrical malpractice insurance from the...
Impact of Malpractice Claims

We studied all family physicians (470) who purchased obstetrical malpractice insurance from the largest malpractice insurer in Washington State (WSPIEA) from 1982 to 1988. One-third discontinued obstetrics but remained in practice, and these physicians were older, more likely to practice in an urban area, and more likely to be in solo practice. Rural family physicians were less likely to quit practicing obstetrics than their urban colleagues. Obstetrically related malpractice claims against family physicians were relatively infrequent and are not a factor in the decision of most family physicians who stop practicing obstetrics.

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Immigrants in Allied Health Professions Objective: This study provides a national snapshot comparing immigrants to the U.S. with...
Immigrants in Allied Health Professions

Objective: This study provides a national snapshot comparing immigrants to the U.S. with native-born citizens who work in healthcare occupations, including their sociodemographic characteristics and the jobs they fill.
Data/Setting: We used a three-year pooled sample (2011 to 2013) of the American Community Survey, an annual household survey conducted by the U.S. Census, selecting a sample of noninstitutionalized individuals age 18 to 75 years in the U.S. labor force.
Design/Methods: We compared native-born U.S. citizens with immigrants, which include naturalized citizens and noncitizens. We examined sociodemographic characteristics including birthplace, gender, age, marital status, metropolitan or non-metropolitan residence, highest level of educational attainment, and state of residence. Among immigrants, we also examined the number of years they had lived in the U.S. and age of immigration, and among naturalized citizens, age at naturalization. We compared the sociodemographic characteristics of healthcare workers having less than a bachelor’s degree with those having a bachelor’s degree and higher by immigrant and citizenship status.
Results:  Immigrants constituted 15.7% of the healthcare labor force. There were about twice as many naturalized citizen (10.5%) as noncitizen (5.3%) immigrants in healthcare. Unemployment in healthcare was lower for naturalized citizens (3.5%) compared with native born citizens (4.8%) and noncitizens (6.0%). Most common birthplaces for naturalized citizens were Asia, the Caribbean, Europe, and Africa. For noncitizens, most common birthplaces were Asia, the Caribbean, Mexico, and Africa. Naturalized citizens were older than native-born citizens and noncitizens; noncitizens were the youngest. Naturalized citizens had immigrated into the U.S. at a younger age and had lived in the U.S. about 10 years longer than noncitizens. Immigrants were more likely than native-born citizens to be married. Over 97% of immigrants lived in metropolitan counties. More naturalized citizens (53.2%) had a bachelor’s degree or higher than native-born citizens (44.4%) and noncitizens (41.1%). Unemployment rates were higher for individuals with less than a bachelor’s degree versus those with a bachelor’s degree or higher, regardless of immigration or citizenship status. Most common healthcare jobs of naturalized citizens included registered nurse (19.8%); nursing/psychiatric/home health aide (18.4%); and physician/surgeon (11.4%). The most common healthcare jobs of noncitizens included allied health occupations such as nursing/psychiatric/home health aide (27.3%) and personal/home care aide (17.6%), as well as registered nurse (12.7%).
Conclusions: Our study suggests that noncitizens in the healthcare labor force are likely to experience greater social and labor market vulnerability than either naturalized citizens or native born citizens. Further research to understand these patterns, the causes of health worker migration, and its consequences. Given shortages of healthcare professionals in underserved communities in the U.S., and the loss of healthcare talent in immigrants’ home countries, the extent of the mismatch between immigrants’ skills and the jobs they occupy is an issue of great concern. Policymakers in the U.S. and other nations need a more thorough understanding of these dynamics of healthcare worker migration and occupational outcomes to make more rational use of scarce and valuable human resources for health.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Davis Patterson, PhD
Contact Info: davisp@uw.edu
 

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IMG On-Line Atlas The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic...
On-Line Atlas of International Medical Graduates

The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic distribution of IMGs over the past 20 years through a series of maps. The maps are intended to provide useful information regarding changes in the global production of IMGs and the distribution of IMGs in the United States over time.

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Idaho's Physicians This study offers data on the size, distribution, demographics, specialties and education history...
Idaho's Physician Workforce

This study offers data on the size, distribution, demographics, specialties and education history of Idaho State’s physician workforce first conducted in 2014 and updated in 2016.

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Idaho Physician Supply, 2009 The Center for Health Workforce Studies provided the University of Washington School of Medicine...
Current and Future Physician Supply in Idaho, 2009

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Idaho with analyses to inform their discussions about whether expansion of and/or modification to the medical school would alleviate future physician shortages in Idaho.

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HPSAs and Rural Health Care Access This study examined the degree to which persistence of primary care health professional services...
Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America

This study examined the degree to which persistence of primary care health professional services area (HPSA) designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services. It used a five-level classification of rural counties measuring partial- vs. whole-county persistence of primary care HPSA designation that stratified rural populations by socioeconomic status (SES), race/ethnicity, primary care supply, health insurance uptake, and access to needed health care services. The study found that those U.S. rural counties that were persistently designated as whole-county HPSAs had much lower SES, and adults residing in these counties reported substantial financial obstacles to obtaining needed health care services. Rural counties that were persistently designated as whole-county HPSAs also faced severe provider shortages, and adults residing in these locations were less likely to have a regular primary care provider. This study was funded by HRSA’s Office of Rural Health Policy.

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HPSA Criteria Evaluation in Washington State One of the most pervasive aspects of the American health scene has been the maldistribution of...
Health Professional Shortage Area (HPSA) Criteria Evaluation Project in Washington State

One of the most pervasive aspects of the American health scene has been the maldistribution of health personnel in rural and urban areas. Notwithstanding much effort at the federal and state level, shortages of physicians and other health professionals persist both in rural and urban areas, especially the remote rural locations and the inner-city urban ones. The current paradox is that despite substantial increases in their numbers of physicians, many rural and urban areas remain underserved. Federal health personnel programs such as the National Health Service Corps (NHSC) are critical tools among relevant federal programs designed to address the geographic maldistribution of health personnel and other health-related resources. But not every community or organizational entity that would like to use these programs has a significant shortage of health personnel. Eligibility for federal health personnel programs such as the NHSC is triggered by designation of an area as a Health Professional Shortage Area (HPSA), and eligibility for other federal interventions requires designation as a Medically Underserved Area (MUA). In fact, eligibility for a considerable number of federal and state programs is based on whether an area or population meets the HPSA and MUA/P criteria. The main activity of this project was to use detailed Washington State data for the 124 generalist Health Service Areas (HSAs) to evaluate alternative variations of the HPSA criteria. Evaluations included examining how sensitive the designations were to changes in the designation methodology and in changes to the method of counting primary care providers. Project results provide comparative information on the numbers of HSAs receiving shortage designations using the various combinations of designation and provider counting methodologies. The project was funded by HRSA’s Office of Rural Health Policy (ORHP) and Bureau of Primary Health Care (BPHC).

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Hospital Closures and MD Supply This study determined whether the supply of physicians decreased subsequent to a rural hospital...
Impact of Hospital Closures on Physician Supply

This study determined whether the supply of physicians decreased subsequent to a rural hospital closure during a nine-year period ending in 1988. The study (1) examined changes in physician manpower before, after, and at the time of the closure and (2) examined the association of town size, hospital size, and distance to other hospitals with hospital closure. The hospital closure towns most likely to lose physicians had few physicians before closure, were relatively remote from both urban areas and other hospitals, were located in sparsely populated counties, and tended to have for-profit ownership.

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Home Care Aides in Washington Beginning in 2011, long-term care workers in Washington who provide services to the elderly or...
Home Care Aides in Washington State: Estimating Current Supply and Future Demand

Beginning in 2011, long-term care workers in Washington who provide services to the elderly or persons with disabilities in residential settings must be certified as home care aides. Estimating the current supply and future demand is difficult because these workers are not currently credentialed by the state. This project uses data on the number of Medicaid clients and facilities using home care aides to estimate current supply, and with estimates of the state’s population growth to 2030, projects the future demand for home care aides in Washington.

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HIT Workforce in Texas The WWAMI Center for Health Workforce Studies served as a technical consultant to Texas State...
Health Information Technology (HIT) Workforce Demand in the State of Texas

The WWAMI Center for Health Workforce Studies served as a technical consultant to Texas State University’s Health Information Technology Workforce Needs Assessment Project. This project, funded by the State of Texas, inventoried statewide HIT workforce needs in order to help ensure that health care employers in Texas have access to well-trained HIT professionals. The study included focus groups and a survey of health care facilities in Texas.

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Health Professions Education in Washington This study used the U.S. Department of Education's Integrated Postsecondary Education Data System...
Health Professions Education in Washington State: 1996-2004 Program Completion Statistics

This study used the U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) database to determine the number, sex and race/ethnicity of persons completing postsecondary health career education programs throughout Washington State. The report shows changes over time for 36 selected programs, ranging from physician, nursing, allied health, dental health, pharmacy and other health care education programs. The 2004 study was funded by the Washington State Workforce Training and Education Board. The 2002 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Health Center Expansion and Recruitment Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals,...
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project

Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals, yet there were no projections of key health professions staffing needs for HCs and proposed new HCs. This collaborative study with the South Carolina RHRC described the staffing needs of rural HCs and ascertained the staffing, recruitment, and retention issues that HC CEOs regarded as most critical. The National Association of Community Health Centers administered a mail questionnaire to the CEOs of all CHCs in the nation (about 845) that profiled their current staff vacancies, projected staffing needs, recruitment and retention issues, center site expansion plans, and CEO perception of policies that would facilitate recruitment and retention. This joint center project was a collaborative one between HRSA’s FORHP, BPHC, and BHPr.

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Health Care for the Rural Uninsured This study described the contributions of family and general practice physicians from Wyoming to...
Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?

This study described the contributions of family and general practice physicians from Wyoming to the health care safety net. We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women were less likely than men to make this mean income, even when controlling for hours worked. Close to two-thirds claimed bad debt of over $10,000, and 29.3% noted forgiven debt of over $10,000. Physicians with less income than the prior year were more likely to decrease their charity care. Wyoming family physicians provide significant amounts of informal safety net care, which is threatened by income loss. Funded by HRSA’s ORHP.

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Future Supply of Family Medicine Physicians This study investigated the implications of declining medical school interest in primary care...
The Future of Family Medicine and Implications for Primary Care Physician Supply

This study investigated the implications of declining medical school interest in primary care careers as it impacts rural and underserved areas. The study examined data from the American Association of Medical Colleges, the 2005 American Medical Association Masterfile, and the American Osteopathic Association Masterfile, as well as survey data from residency directors and students to describe recent trends in medical school interest and national match rates for family medicine and primary care. Funded by HRSA’s FORHP.

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Federal Funding and MD Production This study described the graduates of all American medical schools from 1976 to 1980 and from 1981...
Relationship Between Federal Funding and Medical School Output

This study described the graduates of all American medical schools from 1976 to 1980 and from 1981 to 1985 in terms of their specialty and geographic location and correlated these variables with the amount of Title VII funds received by specific schools during those periods. Two hypotheses that were tested were (1) Title VII has had a positive impact on increasing the proportion of graduates choosing primary care specialties and practicing in rural and underserved areas, and (2) graduates of community-based schools are more likely to choose careers in primary care and to practice in rural and underserved areas than are graduates of traditional medical schools. Data for each medical school were aggregated by school and linked with data on Title VII and other federal funding from 1976 to 1985.

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Family Medicine Residency Network Study This survey project contrasted the role, practice type, and characteristics of graduates from the...
Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs

This survey project contrasted the role, practice type, and characteristics of graduates from the residency network associated with the University of Washington Department of Family Medicine who were located in rural versus urban communities. The geographic trajectories by graduate cohort and program were analyzed. In addition, the extent to which the program has been successful in placing and retaining graduates within rural communities and the region was evaluated.

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Family MD Views of Assisted Suicide With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain...
Family Physician Attitudes Toward Physician-Assisted Suicide

With recent laws allowing physicians to assist in a terminally ill patient’s suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified. This study used data from a 1997 survey of family physicians (FPs) and general practitioners (GPs) in Washington State to determine factors associated with attitudes toward physician-assisted suicide. A questionnaire was mailed to all active FPs/GPs in Washington State. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. One-fourth of the respondents overall indicated support for physician-assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% did not know. Over half would not include physician-assisted suicide in their practices, even if it were legal. Attitudes about physician-assisted suicide varied significantly between urban females and rural males, with the former being more supportive of assisted suicide than the latter. Many respondents, especially females, were uncertain of their positions concerning the legalization of and their willingness to assist suicides. Substantial differences in opinion toward physician-assisted suicide existed between physicians based on gender and rural-urban practice location. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents.

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Family MD Practice Locations In this study, responseded to a survey of graduates from the residency network associated with the...
Geographic Career Trajectories of Family Practice Physicians

In this study, responseded to a survey of graduates from the residency network associated with the University of Washington Department of Family Medicine were analyzed related to their rural and urban career trajectories. This study examined the locational patterns of the graduates in terms of initial site location, practice moves, lengths of stay, prior movement experience, gender, and graduation cohort.

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Emerging Roles in Allied Health Occupations Objective: The purpose of this study was to identify how five domains of emerging roles in...
Emerging Roles in Allied Health Occupations

Objective: The purpose of this study was to identify how five domains of emerging roles in healthcare (care coordination, disease management, navigation, patient education, and peer role) have been incorporated into the job titles and descriptions of healthcare occupations by using Real Time Labor Market Information (RT-LMI) data from LinkUp, a job search engine company. RT-LMI is a source of data that is increasingly used to monitor workforce demand, extracts information from online job ads to track demand for general labor market skills, including for the health workforce.
Design/Methods: Using data obtained by web-scraping tools to extract job ad information from companies, we analyzed job ads in the US from 2014 and 2015. Our team developed a list of healthcare occupations based on the Standard Occupational Classification (SOC) system as well as a list of emerging roles and related job titles based on literature and our team’s expertise. We used natural language processing (NLP) techniques including text parsing, string matching, and word positioning to identify specific skills and roles. We looked at the sample of job ads where the job title field matched one of the occupations from our list of healthcare occupations and looked for emerging role terms that appeared at least once in either the title field or job description. We also looked at the sample of job ads where the job title field matched our list of emerging role terms.
Results: Care coordination was the most common emerging role appearing in healthcare job ads, either in the job title or job description, in 2014 and 2015. Disease management and patient education were more frequently mentioned in 2015 compared to 2014. Physical therapists, social workers, nursing assistants and medical assistants were among the allied health occupations mentioned in job ads in which emerging roles appeared. Care coordination was a dominant emerging role for occupations across all education requirement categories in the job ads examined, and disease management became a more frequently requested emerging role between 2014 and 2015. Jobs requiring a high school degree or below rarely referenced an emerging role despite the relatively high frequency of job ads for healthcare jobs at this education level. Often, where an emerging role was identified in the job title, no other specific healthcare occupation was identified within either the job title or job description, suggesting that these occupations are becoming stand-alone healthcare occupations.
Conclusions: In this study we found that RT-LMI can provide valuable information on the emergence of new skills and roles in the health workforce, including for many allied health occupations. Findings from this study contribute to the development of methods for monitoring and tracking changing healthcare workforce demands using large electronic databases of job ads. This important information on how employers associate skills with posted job titles can help educational institutions, training programs, accrediting bodies and health workforce planners better prepare workers with the competencies to meet market demand.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

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Emergency Care of Rural Elderly This study used Medicare data to compare emergency department (ED) use by rural and urban elderly...
The Emergency Care of the Rural Elderly

This study used Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The Health Care Financing Administration’s National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. This study found that the rural elderly living in remote areas were 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly did not vary meaningfully by location. Most ED visits by this group were for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, local EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Funded by HRSA’s ORHP.

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Educational Strategies to Encourage Rural NP Practice Persistent shortages of primary care physicians in rural areas have increased the need to educate...
What Strategies Are Nurse Practitioner Educational Programs Using to Encourage Rural Practice?

Persistent shortages of primary care physicians in rural areas have increased the need to educate nurse practitioners (NPs) for rural careers. Medical schools have identified factors associated with rural practice by physicians and used this knowledge to develop rural training programs, but less is known about factors associated with rural NP training and practice or the extent to which NP programs deploy such strategies. This study will quantify and describe NP education programs that encourage NPs to practice in rural areas and identify data sources that could be used in future studies of the effectiveness of these programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Economic Impact of HRSA Rural Network & Outreach Grants This study analyzed the economic impact created by HRSA Network Development and Outreach grantees....
Economic Impact Analysis of HRSA's Rural Health Care Services Outreach and Rural Health Network Development Grant Programs

This study analyzed the economic impact created by HRSA Network Development and Outreach grantees. The analyses were conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focused on a cohort of grantees, the study used methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC had a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

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Do IMGs Fill Rural Gaps? Purpose: The contribution that international medical graduates (IMGs) make to reducing the...
Do International Medical Graduates Fill Rural Gaps

Purpose: The contribution that international medical graduates (IMGs) make to reducing the rural-urban physician maldistribution in the United States has implications for medical workforce planning. This study compared the practice location of IMGs and U.S. medical graduates (USMGs) in primary care specialties. Method: We used the 2002 American Medical Association Physician Masterfile to determine the practice location of all primary care physicians. Their locations were linked to Rural-Urban Commuting Areas and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentages of IMGs and USMGs in each type of geographic area for each Census Division and state. Results: One-quarter of the 205,063 primary care physicians were IMGs. They were significantly more likely than USMGs to be female; older; practicing in internal medicine, general practice, or pediatrics; and less likely to practice family medicine. IMGs appeared more likely than USMGs to practice in urban areas, and, with the exception of the East South Central and West North Central Divisions, less likely to practice in rural areas. IMGs were more likely than USMGs to practice in urban areas in 7 states, and less likely to practice in urban areas of 13 states. For rural areas combined, there were 18 states in which IMGs were more likely to practice and 16 in which they were less likely to practice than USMGs. Conclusions: The practice location of IMGs in primary care specialties appeared similar to that of USMGs. While IMGs filled gaps in rural primary care, this varied widely across states. IMGs were a core component of the primary care system, and must be considered in planning the future medical workforce.

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Diversity of Washington Health Professionals The race and ethnicity of Washington's physicians, dentists, dental hygienists, physician...
Race and Ethnicity of Washington's Health Professionals Compared with the State's Population

The race and ethnicity of Washington’s physicians, dentists, dental hygienists, physician assistants and nurse practitioners were compared to that of the overall state population in this snapshot from analyses of the 1999 Washington State health professionals’ licensing and renewal survey data. Funded by HRSA, National Center for Health Workforce Analysis.

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Diversity of the Health Workforce This report explored racial and ethnic diversity among the healthcare workforce by 1)summarizing...
Facilitating Racial and Ethnic Diversity in the Health Workforce

This report explored racial and ethnic diversity among the healthcare workforce by 1)summarizing the state of the evidence from peer-review and grey literature over the past five years on the effectiveness of pipeline programs that seek to promote racial and ethnic diversity in the health workforce, and 2)examining how the racial and ethnic diversity of the health workforce changed over a decade from 2004 to 2013 through analyses of data from the American Community Survey (ACS). This project was funded by HRSA, National Center for Health Workforce Analysis.

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Deregionalization of Rural Perinatal Care The regionalization of rural perinatal care during the 1980s significantly lowered neonatal...
Are Rural Perinatal Care Systems Deregionalizing?

The regionalization of rural perinatal care during the 1980s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study determined whether there was evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization had adversely affected neonatal mortality among infants born to rural residents. We analyzed national Linked Birth Death Data Set data over a 10-year period. The study population included all low-birthweight infants born to rural residents. This study demonstrated the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA’s FORHP.

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Dental Workforce in Montana This project, conducted collaboratively with the Montana Department of Health and the Montana...
State-Level Requirements Model of the General Dental Workforce in Montana

This project, conducted collaboratively with the Montana Department of Health and the Montana Dental Association, produced policy-relevant Montana dental workforce shortage information through data collected in a survey of that state’s dentists. The survey obtained information about practice characteristics of dentists and dental hygienists, including information about provider supply and the provision of care to the underserved populations of the state. Funded by HRSA, National Center for Health Workforce Analysis. Findings from this study were integrated for publication with findings from dental surveys in five other states (conducted through the WWAMI Rural Health Research Center).

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Dental Workforce and Unmet Needs in Washington This project used licensure data from Washington State to examine the supply of, and requirements...
The Distribution of the Dental Workforce and Its Relationship to Unmet Needs in Washington State

This project used licensure data from Washington State to examine the supply of, and requirements for, dentists and dental hygienists in 125 generalist health service areas in the state. Funded by HRSA, National Center for Health Workforce Analysis.

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Demand for 5 Health Occupations in Washington With funding from the Washington State Workforce Training and Education Coordinating Board, CHWS...
Current and Future Demand for Home Care Aides, Nursing Assistants Certified, Medical Assistants, Licensed Practical Nurses, and Associate's Degree Registered Nurses in Washington State

With funding from the Washington State Workforce Training and Education Coordinating Board, CHWS researchers carried out a study to assess future demand for five specific occupations in Washington State: home care aides, nursing assistants certified, medical assistants, licensed practical nurses, and associate’s degree registered nurses. Of particular interest was how the roles of these occupations may be changing with implementation of the Affordable Care Act. The project included a subcontract with the Western Washington Area Health Education Center.

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Leveraging Data for Allied Health Workforce Research This study compared and discussed how estimates of nine allied health professionals vary across...
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability

This study compared and discussed how estimates of nine allied health professionals vary across secondary data sets such as the American Community Survey, Current Population Survey, Occupational Employment Statistics, and the National Provider Identifier Registry. This study helped to identify gaps where future data collection and research are needed. The nine allied health occupations are occupational therapists, physical therapists, respiratory therapists, speech-language pathologists, clinical laboratory technologists/technicians, dental hygienists, diagnostic-related technologists/technicians, medical assistants, and social workers.

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Contributions of Physicians, APNs, and PAs to Rural Primary Care This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs),...
The Current Contribution of Physicians, Advanced Practice Nurses, and Physician Assistants to the Rural Primary Care Workforce

This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs), and physician assistants (PAs) regarding their primary care visit productivity and scope of practice. Through surveys, this study examined the contributions of physicians, APNs, and PAs by state, degree of practice rurality, practice characteristics, and primary care HPSA status in order to provide information on a range of rural primary care workforce needs in the coming decades. Funded by HRSA’s Office of Rural Health Policy.

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Community Paramedicine Research Consensus Conference Background: Community paramedicine is a new model of providing access to basic health care...
National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda

Background: Community paramedicine is a new model of providing access to basic health care services. Community paramedicine extends paramedics’ traditional emergency response roles through additional education that enables them to see patients in their home or community setting and perform procedures already in their skill set. Community paramedics provide care under the supervision of an ordering physician or advance practice provider. Community paramedics are providing these kinds of services for otherwise underserved communities in demonstration sites in the U.S. and Canada. While there are reports of successful implementation of this novel approach to expanding primary care access, there is a paucity of objective, systematic research on the outcomes of these programs. This project identified appropriate research questions and appropriate data to increase understanding of the outcomes of community paramedicine. Goal: This project developed a national research agenda for the emerging field of community paramedicine based on facilitated discussions at a National Consensus Conference on Community Paramedicine. Collaboration: The study was conducted collaboratively by researchers at the University of Washington (UW) WWAMI Rural Health Research Center (RHRC) and the North Central Emergency Medical Services Institute. Funding was from a conference grant by the Agency for Healthcare Research and Quality. The UW’s WWAMI RHRC researchers completed a summary of topics and key points discussed during the National Consensus Conference on Community Paramedicine (October 1-2, 2012) and a community paramedicine research agenda report.

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Chronic Illness among Rural Residents This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine...
The Burden of Chronic Illness Among Rural Residents: A National Study

This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine trends–by type of geographic area, race/ethnicity, and risk factors–in hypertension, diabetes, hypercholesterolemia, and asthma, as well as patterns of screening for two of these conditions. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Characteristics of RNs whose Washington Licenses have Expired This survey of RNs who did not renew Washington licenses in 2002-2003 examined why these RNs...
RNs with Expired Licenses in Washington

This survey of RNs who did not renew Washington licenses in 2002-2003 examined why these RNs dropped their Washington licenses, where they were located, and their views regarding the nursing profession. Funded by HRSA National Center for Health Workforce Analysis, through Congressional Appropriation to the UW CHWS.

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Characteristics of National Rural Nurse Workforce This national study characterized changes in the demographic, education, and practice...
Long-Term Trends in Characteristics of the Rural Nurse Workforce: A National Health Workforce Study

This national study characterized changes in the demographic, education, and practice characteristics of registered nurses (RNs) in rural and urban areas from 1980 to 2004. Study data came from the National Sample Survey of Registered Nurses (NSSRN) collected between 1980 and 2004. RNs were categorized into urban, large rural, small rural, and isolated small rural by residence and work location using the Rural-Urban Commuting Area taxonomy. The study examined changes since 1980 in rural RN number, percent employed in nursing, age, gender, race/ethnicity, age at first RN degree, types of degrees attained, type of work, salaries, the types of areas where the RNs work, and their likely commuting patterns. By examining trends in rural RNs characteristics over the past two decades, this study provided important information for projecting future trends in RN supply for rural communities.

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Changes in MD Supply National rural health policy development depends on an accurate and up-to-date assessment of...
National Changes in Physician Supply

National rural health policy development depends on an accurate and up-to-date assessment of physician supply. This project described the supply of generalist physicians and osteopaths in rural areas of the United States. We used data from the AMA and Area Resource File to determine the total supply of practicing physicians in metropolitan and nonmetropolitan counties in 2005. We used Urban Influence Codes to classify nonmetropolitan counties based on their adjacency to a metropolitan county and the size of the largest urban place within the county. We assessed the supply of physicians in the smallest and most isolated areas of the country and analyzed rural physician supply on a state-by-state and regional basis. Funded by HRSA’s FORHP.

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Career Paths of Allied Health Professionals Aims: To explore career transitions among individuals in select entry‐level healthcare...
Career Paths of Allied Health Professionals

Aims: To explore career transitions among individuals in select entry‐level healthcare occupations.
Background: Entry‐level healthcare occupations are among the fastest growing occupations in the United States. Public perception is that the healthcare industry provides an opportunity for upward career mobility given the low education requirements to enter many healthcare occupations. The assumption that entry‐level healthcare occupations, such as nursing assistant, lead to higher‐skilled occupations, such as registered nurse, is under‐explored.
Design: We analyzed data from the Panel Study of Income Dynamics, which is a nationally representative and publicly available longitudinal survey of US households.
Methods: Using longitudinal survey data, we examined the job transitions and associated characteristics among individuals in five entry‐level occupations at the aide/assistant level over a 10‐year timeline (2003‐2013) to determine whether they stayed in healthcare and/or moved up in occupational level over time.
Results/Findings: This study found limited evidence of career progression in healthcare in that only a few of the individuals in entry‐level healthcare occupations moved into occupations such as nursing, that required higher education. While many individuals remained in their occupations throughout the study period, we found that 28% of our sample moved out of these entry‐level occupations and into another occupation. The most common “other” occupation categories were “office/administrative” and “personal care/services occupations.” Whether these moves helped individuals advance their careers remains unclear.
Conclusion: Employers and educational institutions should consider efforts to help clarify pathways to advance the careers of individuals in entry‐level healthcare occupations.
This study resulted in a published paper in the Journal of Advanced Nursing, abstract is included here in the study description.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

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Care for Lung Disease among Rural/Urban Medicare Beneficiaries This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural...
National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?

This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural and urban patients hospitalized with chronic obstructive lung disease to prescribed home oxygen and the needed equipment. Funded by HRSA’s FORHP.

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Care for Acute Myocardial Infarction in Rural Hospitals: 1994-1995 Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most...
Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995

Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most recommended interventions require no sophisticated technology and should be available in rural and urban hospitals. This study examined the quality of AMI care in rural hospitals. It was a cohort study using data from the 1994 and 1995 Centers for Medicare & Medicaid Services’ Cooperative Cardiovascular Project and the 1995 American Hospital Association’s Annual Survey of Hospitals. The study included U.S. acute-care hospitals caring for patients with AMI, and Medicare beneficiaries ages 65 and older directly admitted to four types of acute-care hospitals–remote small rural, small rural, large rural, and urban–for a confirmed AMI between 1994 and 1995. Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive recommended AMI treatments. Medicare patients treated in rural hospitals were less likely than urban hospitals’ patients to receive aspirin during hospitalization or at discharge, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only one treatment–ACE inhibitors at discharge–was used more for patients in rural hospitals. Medicare patients in rural hospitals had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals. Efforts are needed to help hospital medical staffs, especially those in rural areas, develop systems to ensure that patients receive recommended AMI treatments. Funded by HRSA’s ORHP.

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Cancer Screening in Rural America This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to...
Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?

This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to explore the prevalence and trends in screening for four types of cancer (breast, colorectal, cervical, and prostate) among survey respondents from urban and various types of rural areas and among white compared to minority populations. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Cancer Care for Rural Colorectal Cancer Patients This study compiled a comprehensive database linking Surveillance Epidemiology and End Results...
Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study

This study compiled a comprehensive database linking Surveillance Epidemiology and End Results (SEER) cancer registry, Medicare claims, American Medical Association Masterfile, and other data to examine access to cancer services in a sample of rural, Medicare-insured colorectal cancer patients of different racial and ethnic groups. Funded by HRSA’s FORHP.

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Birth Care for Rural/Urban American Indians While American Indians (AIs) constitute a substantial minority population in many rural areas,...
Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women

While American Indians (AIs) constitute a substantial minority population in many rural areas, population-based research on the health status of AI women and infants is limited. This study used the National Linked Birth Death Certificate Data Set for 1989 and 1991 to compare the perinatal risk factors, prenatal care use, birth outcomes, and infant death rates of rural AIs, urban AIs, and whites. Results from this study should help administrators and policy makers to better understand the health care needs of this population, as well as the targeted interventions needed to improve birth outcomes and infant health status. Funded by HRSA’s ORHP.

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Behavioral/Mental Health workforce for Integrated Primary Care This study provided insight regarding the workforce needed to integrate behavioral health with...
The Workforce Needed to Integrate Behavioral/Mental Health Workforce with Primary Care

This study provided insight regarding the workforce needed to integrate behavioral health with primary care in order to develop health workforce-related plans and policies, with an emphasis on state-level efforts, which will increase population-based access to behavioral health care services through primary care settings.

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BBA and Rural Residency Training This national survey examined the proportion of rural-based family medicine residencies across the...
Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study

This national survey examined the proportion of rural-based family medicine residencies across the United States that have ceased operations since 2000, the residency match patterns of existing programs, changing proportions of International Medical Graduates (IMGs) and U.S. Medical Graduates (USMGs), and major issues facing rural residency programs. Funded by HRSA’s FORHP.

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Barriers to Rural Residencies This project examined issues related to establishment and maintenance of residencies and residency...
Barriers to Rural Residencies Project

This project examined issues related to establishment and maintenance of residencies and residency tracks in rural America. The project involved both a literature review and interviews with key informants related to the issues surrounding rural residency programs. While the project emphasized generalist residencies, it was not limited to them. The policy paper discussed issues associated with retaining and starting rural residencies and tracks such as their training cost and clinical implications, credentialing constraints, and staffing problems. Understanding the issues surrounding the establishment of rural residencies is important for federal and state legislators and administrators as they revamp the nation’s graduate medical education system. Funded by HRSA’s ORHP.

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APRN Distribution in the U.S. This study analyzed 2010 Centers for Medicare and Medicaid Services' National Provider Identifier...
Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.

This study analyzed 2010 Centers for Medicare and Medicaid Services’ National Provider Identifier (NPI) records to assess the usefulness of the dataset to describe APRN distribution across the United States. There were adequate NPI data to describe urban and rural location of certified registered nurse anesthetists (CRNAs) and nurse practitioners (NPs) in the U.S. and relative per capita supply. Practice location was estimated by linking Rural-Urban Commuting Area codes to NPI provider ZIP codes. Chi-square testing examined provider supply by geographic locations. Multivariate hierarchical regression testing identified whether rural practice location was related to practice autonomy, per capita provider supply, or gender. Funded by the American Nurses Association.

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Ambulatory Care for Rural Elderly Diabetes is a common serious chronic disease where careful clinical monitoring can improve the...
Ambulatory Care and the Rural Elderly

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.

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Ambulatory Care for Rural Elderly Diabetes is a common serious chronic disease where careful clinical monitoring can improve the...
Ambulatory Care and the Rural Elderly

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...
Community Colleges’ Contributions to the Education of Allied Health Professionals in Rural Areas of the United States

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...
Community Colleges' Contributions to the Education of Allied Health Professionals in Rural Areas of the United States

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Alaska Physicians This study offered data on the size, distribution, demographics, specialties and education history...
Alaska's Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Alaska State’s physician workforce first conducted in 2014 and updated in 2016.

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Alaska Physicians This study offered data on the size, distribution, demographics, specialties and education history...
Alaska's Physician Workforce

This study offered data on the size, distribution, demographics, specialties and education history of Alaska State’s physician workforce first conducted in 2014 and updated in 2016.

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Aging Rural Physician Workforce This study identified rural locations with high proportions of generalist physicians nearing...
The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?

This study identified rural locations with high proportions of generalist physicians nearing retirement age. As fewer young physicians choose generalist careers, the retirement of older physicians may place additional strain on rural generalist supply. This study quantified the extent to which rural generalist physician shortages may be exacerbated by physician retirement, focusing on known shortage locations. The study used data from the American Medical Association and American Osteopathic Association 2005 Masterfiles.
This study was funded by HRSA’s Office of Rural Health Policy.

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Access to and Outcomes of Obstetric Care Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical...
Relationship Between Access to Obstetrical Care and Process and Outcome of Care

Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical care in rural communities and birth outcomes (see working paper #4). The Obstetrical Process and Outcome of Care Study compared rural versus obstetrical care and outcomes from birth certificates. This study examined the relationship between access to and availability of care (number of local providers available who provide obstetrical care and who care for pregnant Medicaid women) and quality and cost of care. Sources of data included Washington State birth certificates and hospital discharge abstracts, supplemented with information on hospitals, communities, and provider supply. Findings from this study further illuminate the connection between poor geographic access, Medicaid access, and poor quality care.

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2004 Rural-Urban Commuting Areas (V2) This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that...
Introduction to and Description of the 2004 (Version 2) Rural-Urban Commuting Areas (RUCAs)

This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that defines rural and urban based on Census Bureau definitions and work commuting patterns. The RUCA taxonomy is a tool based on the sizes of cities and towns and their functional relationships as reflected by commuter patterns. Funded by HRSA’s FORHP.

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Low Skilled, Low-wage Workers in Health Care Objective: This study investigated the socioeconomic well-being of healthcare...
Impacts of Greater Use of Low Skilled, Low-wage Workers in Health Care Delivery

Objective: This study investigated the socioeconomic well-being of healthcare workers.
Data/Setting: We analyzed 2015 data from an ongoing monthly household survey called the Annual Social and Economic Supplement of the Current Population Survey (CPS). We restricted our analysis to employed respondents age 18 to 75 and used survey weights to generalize the results to the civilian non-institutionalized U.S. adult population.
Design/Methods: Using the BLS Occupational Outlook Handbook, we assigned individuals into one of five categories based on the minimum education requirement of the occupation in which they were employed at the time of the survey: 1) high school degree or equivalent or below; 2) post-secondary non-degree award, 3) associate degree, 4) bachelor’s degree, and 5) above bachelor’s degree.  Across these education categories and by healthcare setting, we compared socioeconomic well-being measures of these individuals, which include whether their hourly wage was under $15 per hour, whether they were at or below the poverty level, whether they lacked health insurance, and whether they relied on state/federal social assistance programs. We used unpaired two-sample t-tests to compare mean values between education requirement categories.
Results:  Almost two-thirds of healthcare occupations in this study required less than a bachelor’s degree for entry, consistent with statistics that the majority of healthcare occupations are low- to middle-skilled. Those working in occupations requiring a high school degree or below was the category with the highest percentage of people of color. There is a potential mismatch between skill and occupation; for example, over half of the individuals working in occupations requiring a high school degree or less attained more than a high school level of education. Despite working in healthcare settings, individuals across all education categories lacked health insurance ranging from 3.8% among those working in jobs requiring a bachelor’s degree to 15.6% among those working in jobs requiring a high school degree or below. Uninsured rates were significantly higher among part-time workers in ambulatory and long-term care settings. Among those in occupations requiring a high school degree or below, 26.3% relied on the Earned Income Tax Credit, 18.2% relied on Medicaid, and 18.7% relied on the Supplemental Nutrition Assistance Program. Long-term care settings have the highest proportion of individuals working in occupations requiring a high school degree or less, and 80% of these individuals relied on one or more social assistance programs.
Conclusions: Workforce planners and policymakers who advocate for healthcare as a promising industry with growing entry level job opportunities need to ensure that those entering these occupations have a viable career path. Employers wanting to reduce turnover for their workers in low-skilled occupations should find ways to address financial risks and worker’s reliance on state/federal assistance programs.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2015-09-21"
Low Skilled, Low-wage Workers in Health Care Objective: This study investigated the socioeconomic well-being of healthcare...
Impacts of Greater Use of Low Skilled, Low-wage Workers in Health Care Delivery

Objective: This study investigated the socioeconomic well-being of healthcare workers.
Data/Setting: We analyzed 2015 data from an ongoing monthly household survey called the Annual Social and Economic Supplement of the Current Population Survey (CPS). We restricted our analysis to employed respondents age 18 to 75 and used survey weights to generalize the results to the civilian non-institutionalized U.S. adult population.
Design/Methods: Using the BLS Occupational Outlook Handbook, we assigned individuals into one of five categories based on the minimum education requirement of the occupation in which they were employed at the time of the survey: 1) high school degree or equivalent or below; 2) post-secondary non-degree award, 3) associate degree, 4) bachelor’s degree, and 5) above bachelor’s degree.  Across these education categories and by healthcare setting, we compared socioeconomic well-being measures of these individuals, which include whether their hourly wage was under $15 per hour, whether they were at or below the poverty level, whether they lacked health insurance, and whether they relied on state/federal social assistance programs. We used unpaired two-sample t-tests to compare mean values between education requirement categories.
Results:  Almost two-thirds of healthcare occupations in this study required less than a bachelor’s degree for entry, consistent with statistics that the majority of healthcare occupations are low- to middle-skilled. Those working in occupations requiring a high school degree or below was the category with the highest percentage of people of color. There is a potential mismatch between skill and occupation; for example, over half of the individuals working in occupations requiring a high school degree or less attained more than a high school level of education. Despite working in healthcare settings, individuals across all education categories lacked health insurance ranging from 3.8% among those working in jobs requiring a bachelor’s degree to 15.6% among those working in jobs requiring a high school degree or below. Uninsured rates were significantly higher among part-time workers in ambulatory and long-term care settings. Among those in occupations requiring a high school degree or below, 26.3% relied on the Earned Income Tax Credit, 18.2% relied on Medicaid, and 18.7% relied on the Supplemental Nutrition Assistance Program. Long-term care settings have the highest proportion of individuals working in occupations requiring a high school degree or less, and 80% of these individuals relied on one or more social assistance programs.
Conclusions: Workforce planners and policymakers who advocate for healthcare as a promising industry with growing entry level job opportunities need to ensure that those entering these occupations have a viable career path. Employers wanting to reduce turnover for their workers in low-skilled occupations should find ways to address financial risks and worker’s reliance on state/federal assistance programs.
This study resulted in a full report and a 2-page policy brief that can be found in the publications section of our website.
Lead Researcher: Bianca K. Frogner, PhD
Contact Info: bfrogner@uw.edu

Complete HRSA: HWRC Allied Health 2015-09-21"
Recruitment to Rural Residency Programs: Match Rates and Best Practices This study explores the history of National Residency Matching Program (NRMP) match rates for...
Recruitment to Rural Residency Programs: Match Rates and Best Practices

This study explores the history of National Residency Matching Program (NRMP) match rates for rurally located family medicine residency programs over the past 25 years (1995-2020) in an effort to examine the widely held perception that low match rates equate to unfavorable program outcomes and to identify successful recruitment strategies for rural programs and for recruitment to rural practice generally.

For more information, contact Randall Longenecker, MD

In Progress HRSA 2021-05-24"
Routes to Rural Readiness: Enhancing Recruitment and Retention of Nurse Practitioners in Rural Primary Care Through Residencies Encouraging and supporting nurse practitioners (NPs) to practice in rural clinical sites can...
Routes to Rural Readiness: Enhancing Recruitment and Retention of Nurse Practitioners in Rural Primary Care Through Residencies

Encouraging and supporting nurse practitioners (NPs) to practice in rural clinical sites can alleviate rural primary care provider shortages. This study will identify characteristics of successful models of postgraduate NP clinical training programs that support NPs’ transition to rural employment and effective practice through interviews with key stakeholders at rural and rural-serving primary care NP residencies.

For more information, contact Louise Kaplan, PhD, ARNP, FNP-BC, FAANP, FAAN

In Progress HRSA 2021-05-24"
The Impact of Telepsychiatry Services on the Training of Rural Primary Care Teams in Integrated Behavioral Healthcare There is a shortage of rural primary care personnel with expertise in team care for patients with...
The Impact of Telepsychiatry Services on the Training of Rural Primary Care Teams in Integrated Behavioral Healthcare

There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders. Building the workforce for this population is a national priority. In this study we investigated the feasibility of regular systematic case reviews through telepsychiatric consultation, within collaborative care for depression, as a continuous training and workforce development strategy in rural clinics. Weekly systematic case reviews using telepsychiatric consultation served both as a model for patient care and as a training and workforce development strategy in rural primary care sites delivering collaborative care. These are important benefits to consider in implementing the collaborative care model of behavioral health integration.

For more information contact: Morhaf Al Achkar, MD, PhD

Complete HRSA 2021-05-24"
Measuring the Commitment of Health Professions Schools to Rural Primary Care Despite some medical schools’ stated intentions to produce rural or primary care physicians,...
Measuring the Commitment of Health Professions Schools to Rural Primary Care

Despite some medical schools’ stated intentions to produce rural or primary care physicians, these health professionals remain in short supply. This study describes the rurally oriented organizational and educational factors of U.S. medical schools. The research team conducted a search of publicly available data and compiled information on rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016 and updated in 2019 (see article below). Few medical schools (8.2%) expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program.

A forthcoming companion paper will report on data from the American Medical Association to examine which U.S. medical schools produce high proportions of rural primary care physicians and the factors that predict that output.

For more information contact: Randall Longenecker MD

Complete HRSA 2021-05-24"
How Can We Support Rural-Centric Residency Programs as Unified ACGME Accreditation Approaches in 2020? The Accreditation Council for Graduate Medical Education (ACGME) will be the single accrediting...
How Can We Support Rural-Centric Residency Programs as Unified ACGME Accreditation Approaches in 2020?

The Accreditation Council for Graduate Medical Education (ACGME) will be the single accrediting body for all osteopathic and allopathic residencies beginning in 2020. All small and rural residencies face vulnerabilities in achieving and maintaining accreditation, but osteopathic residencies may now be particularly challenged. Through a review of ACGME applications, interviews, and a survey of programs, this study seeks to identify challenges as well as resources and solutions that can support rural and small residency programs in primary care and several other specialties critical to rural communities.

For more information, contact Davis Patterson, PhD

In Progress HRSA 2021-05-24"
Routes to Rural Readiness: Enhancing Clinical Training Experiences for Nurse Practitioner Practice in Rural Primary Care Advanced practice registered nurses (APRNs) provide vital care in rural and safety-net settings....
Routes to Rural Readiness: Enhancing Clinical Training Experiences for Nurse Practitioner Practice in Rural Primary Care

Advanced practice registered nurses (APRNs) provide vital care in rural and safety-net settings. This study identifies, describes, and compares the approaches of rural-oriented NP education programs to facilitate the NP transition from education to practice in rural settings. Preparing NP students effectively during their education may be key to their success in rural practice.

In addition, because research regarding effective strategies for recruiting and retaining rural or safety-net providers often focuses on physicians or combinations of health care professionals, we also conducted a scoping review using MEDLINE and CINAHL to identify effective strategies and research gaps specific to recruiting and retaining APRNs in rural and safety-net settings. We found 13 articles published between 1990 and 2019. Educational experiences and loan repayment obligations influenced APRNs to seek employment in both types of settings. Rural connectedness or satisfaction with the community, having a mentor and supportive work environment, and salary and benefits influenced retention in rural practice. Post-graduate NP residency and an NP-physician team-based care model influenced retention in safety-net settings. We found a limited quantity of evidence for strategies that encourage a strong rural and safety-net APRN workforce, indicating need for additional research.

For more information contact: Louise Kaplan, PhD, ARNP, FNP-BC, FAANP, FAAN

Complete HRSA 2021-05-24"
How Can We Strengthen Rural Opportunities in K-16 Education to Promote Primary Care Health Careers? Health career pathway programs can promote and prepare rural students in grades kindergarten...
How Can We Strengthen Rural Opportunities in K-16 Education to Promote Primary Care Health Careers?

Health career pathway programs can promote and prepare rural students in grades kindergarten through college (K–16) for health careers, but little is known about the prevalence and characteristics of these programs in the U.S. This mixed-methods study provides a baseline description of health career pathway programs for rural K–16 students through a scoping review, survey, and semi-structured interviews with program directors. Among 165 programs responding to the survey, motivational or health career awareness (95.1%), health care exposure (92.0%), and mentorship (70.2%) were the most commonly used strategies. About one-third of programs (34.6%) had discontinued at least one strategy in the past three years, often due to loss of funding or a change in priorities. While reported outcomes suggested positive program effects, evaluations lacked rigor to draw definitive conclusions about program success. This study serves to generate hypotheses for further studies examining characteristics of student participants, program strategies and activities, and outcome measurement for health career pathway programs.

Complete HRSA 2021-05-24"
Are Family Physicians Trained in Small Rural Residencies of Comparable Quality to Family Physicians Overall? Because residency location is a strong determinant of eventual practice location, residency...
Are Family Physicians Trained in Small Rural Residencies of Comparable Quality to Family Physicians Overall?

Because residency location is a strong determinant of eventual practice location, residency training in rural communities is critical for meeting rural workforce needs. Yet the quality of training and medical care provided by graduates of small rural family medicine residency programs is sometimes questioned. Using data from the American Board of Family Medicine, this study seeks to demonstrate the value of rural training by examining how graduates of small rural family medicine programs compare with other family medicine residency graduates on ratings of competence and medical knowledge, current scope of practice, and other indicators of value.

For more information contact: Davis Patterson, PhD

In Progress HRSA 2021-05-24"
Routes to Rural Readiness: Enhancing Rural Clinical Training Experiences for Physician Assistants Rural provider shortages in primary care can be alleviated by encouraging and supporting physician...
Routes to Rural Readiness: Enhancing Rural Clinical Training Experiences for Physician Assistants

Rural provider shortages in primary care can be alleviated by encouraging and supporting physician assistants (PAs) to practice in rural areas. This study will survey and interview PA program directors to describe the approaches of rurally oriented PA programs as well as the availability and varying models of rural clinical training in the most successful programs.

For more information contact: Eric Larson, PhD

In Progress HRSA 2021-05-24"
Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission Increased medical school class sizes and new medical schools have not addressed the workforce...
Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission

Increased medical school class sizes and new medical schools have not addressed the workforce issues in rural communities. This study examined the admissions policies of U.S. allopathic and osteopathic medical schools that target applicants likely to enter rural practice. We surveyed Deans of Admissions about their schools’ targeted admissions strategies aimed at recruitment and selection of students likely to practice rurally. To gain deeper insight into the admissions policies, we conducted interviews with key medical schools. 133 of 185 (71.8%) U.S. medical schools responded to our survey. Most respondents (69.2%) reported a targeted process to recruit and select students likely to practice in a rural setting, indicating widespread awareness of workforce challenges. This study demonstrated varying approaches to and allocation of resources towards admissions targeting, especially the application and interviewing processes, with the more resource-intensive efforts occurring less commonly. Interviews with personnel from 10 schools identified key themes pertaining to motivations for targeted admissions strategies, needed resources, challenges to success, and recommendations for schools contemplating admissions changes. This study was conducted by the Collaborative for Rural Primary care Research, Education, and Practice (Rural PREP), a HRSA-funded project of the University of Washington, Ohio University, and the University of North Dakota.

Complete HRSA 2021-04-27"
Methamphetamine Use, Mental Health Comorbidities, and Treatment in Rural and Urban Areas Methamphetamine (meth) use has been on the rise in rural and urban areas of the U.S., but more so...
Methamphetamine Use, Mental Health Comorbidities, and Treatment in Rural and Urban Areas

Methamphetamine (meth) use has been on the rise in rural and urban areas of the U.S., but more so in rural areas. Meth use is also unevenly distributed across U.S. regions, with more in the West, but pockets of growing meth use are emerging in other regions as well. Alarm is growing about meth use as a serious public health problem, particularly because there are no proven treatments for meth addiction. National trend data are available on meth use, but information at the subnational level has been lacking to inform regional and local policy.

This study aims to identify hotspots and trends in rural versus urban meth use, including analyses within sub-rural geographies and U.S. regions to allow better targeting of resources for prevention and treatment. We will also examine meth use in combination with other substances (opioids and alcohol), mental health comorbidities, and perceived need for and receipt of treatment by people who use meth and those with meth use disorder. We will use 2016-2018 data from the National Survey on Drug Use and Health (NSDUH) to characterize meth use, treatment, and association with other mental health comorbidities.

Contact

Davis Patterson, PhD

In Progress HRSA 2021-03-16"
The Current Distribution of the General Surgery Workforce in Rural America The United States is in a long-standing and worsening shortage of general surgeons. While the...
The Current Distribution of the General Surgery Workforce in Rural America

The United States is in a long-standing and worsening shortage of general surgeons. While the number of physicians (including the number of general surgeons) has increased over the past fifteen years, the supply of general surgeons per 100,000 population has decreased. The effect of this shortage is felt strongly in rural areas of the nation, where the shortages are likely to be far more pronounced than those in urban areas, and where residents are less likely to have local alternatives when in need of surgical services. General surgeons contribute substantially to the financial viability of rural hospitals and provide essential backup to rural primary care physicians especially in the areas of emergency surgery and obstetrical, gynecological, and orthopedic procedures. Rural populations clearly bear a disproportionate share of the burden of poor local access to surgical services and the concomitant higher risk of poor outcome or death. This project describes the supply and geographic distribution of general surgeons across rural/urban, intra-rural area types and regions using the American Medical Association (AMA) Physician Masterfile data and Claritas population data to calculate general surgeon/population ratios.

Contact

Eric H. Larson, PhD

Complete HRSA 2021-03-16"
Examining the Potential Impact of Multiple Payment Policies on Rural versus Urban Home Health Agencies Home health agencies are navigating several new and upcoming Medicare payment policy changes. These...
Examining the Potential Impact of Multiple Payment Policies on Rural versus Urban Home Health Agencies

Home health agencies are navigating several new and upcoming Medicare payment policy changes. These changes include 1) revised targeting and beginning of phase out of rural add-on payments which became effective in 2019; 2) the Patient-Driven Groupings Model (PDGM), a new prospective payment system scheduled to be implemented in 2020; and 3) the Home Health Value-Based Purchasing (HHVBP) demonstration. All Medicare-certified home health agencies (~12,000) serving fee-for-service beneficiaries will be impacted by the PDGM. The revised rural add-on payments impact all home health agencies that serve rural beneficiaries. About 2,000 home health agencies are currently participating in the HHVBP demonstration, of which 13% are rurally located. The cumulative impact of these policies on home health agencies has not been explored. The proposed study will estimate the cumulative impact on home health agencies, comparing home health agencies operating under one, two, or all three policies. We hypothesize there will be differential impacts based on rural-urban status, community factors, and home health agency characteristics. We will estimate and report impacts by rural-urban status, community factors, and home health agency characteristics. We will compare the cumulative impacts with the separate impacts of the three individual payment policy changes. We will then identify rural counties where access to and/or quality of home health care may be most impacted by the cumulative payment policy changes.

Contact

Tracy Mroz, PhD, OTR/L

In Progress HRSA 2021-03-16"
What is the Geographic Distribution of the Workforce with a DEA Waiver to Prescribe Buprenorphine? This study found that the number of clinicians with a Drug Enforcement Agency (DEA) waiver to...
What is the Geographic Distribution of the Workforce with a DEA Waiver to Prescribe Buprenorphine?

This study found that the number of clinicians with a Drug Enforcement Agency (DEA) waiver to provide medication treatment for opioid use disorder (MOUD) more than doubled from December 2017 to July 2020, from 37,869 to 98,344. The availability of DEA-waivered clinicians has increased across all geographic categories. Nearly two thirds of all rural counties (63.1%) had at least one clinician with a DEA waiver but more than half of small and remote rural counties had none. There were also significant differences in access by US Census Division.

The study found that the substantial expansion in the number and types of providers who can prescribe buprenorphine, combined with the increased number of patients waivered clinicians can treat at one time, offers significant, but not fully realized, potential to curtail the OUD epidemic in rural communities.

Contact

Holly Andrilla, MS

Complete HRSA 2021-03-16"
Overcoming Barriers to Providing Rural Obstetrical Training for Physicians Rural communities face diminishing availability of obstetrical (OB) services. Nearly a third of...
Overcoming Barriers to Providing Rural Obstetrical Training for Physicians

Rural communities face diminishing availability of obstetrical (OB) services. Nearly a third of rural counties in 2019 had no OB clinicians. Family physicians are the most common health professional providing rural OB care, but more than half of rural counties had no family physicians who delivered babies in 2019, and this number is declining. Delivery by family physicians is associated with lower rates of caesarian section births, indicating that this workforce is important not only to increase rural access to OB care, but also to improve quality and reduce costs. Meanwhile, the U.S. is experiencing a national shortage of obstetricians and gynecologists (OB-GYNs), again more acutely in rural areas. How widespread rural OB training is and how expansion of this training can best be supported are not well understood. This study seeks to describe the availability, characteristics, and output of rural OB training programs, including family medicine residencies and OB fellowships as well as OB-GYN. We identify barriers, facilitators, and solutions to support rural OB training. Study findings can help policymakers and rural health professional educators develop new initiatives to help ensure the availability of a robust rural OB workforce.

Lead researcher

Davis Patterson, PhD

Healthcare access Maternal Health Women
In Progress HRSA 2020-10-23"
Trends in Health Workforce Supply in the Rural U.S. This study describes the supply and distribution of selected health professionals in the rural U.S....
Trends in Health Workforce Supply in the Rural U.S.

This study describes the supply and distribution of selected health professionals in the rural U.S. nationally, and within Census Divisions, providing a nuanced description of the variability in supply and geographic distribution. We also examine historic variation, overall and per capita, in rural/urban, regional, and intra-rural supply using several data sources, such as the Area Health Resource File (AHRF), the National Plan and Provider Enumeration System (NPPES), and Urban Influence Codes (UICs). Depending on data availability, health professionals to be analyzed include primary care physicians, nurse practitioners, physician assistants, dentists, behavioral health providers (including psychiatrists, psychologists, psychiatric nurse practitioners, social workers, and counselors), obstetric providers (including obstetricians, advanced practice midwives, and midwives) and specialist physicians (overall and individual specialties not listed previously, including general surgeons). Tracking the trends in the rural workforce will allow for the development of solutions to address access disparities. We also identify gaps in data availability by profession and time period as a spur to promoting improved data collection and reporting on the rural health workforce.

Lead researcher

Davis Patterson, PhD

behavioral health Healthcare access Nurse and nurse practitioners physician assistants workforce
In Progress HRSA 2020-10-23"
Comparing Utilization and Quality of Home Health Care Between Medicare Fee-for-Service and Medicare Advantage Beneficiaries by Rural-Urban Status This study uses new Medicare Advantage (MA) encounter data from the Centers for Medicare &...
Comparing Utilization and Quality of Home Health Care Between Medicare Fee-for-Service and Medicare Advantage Beneficiaries by Rural-Urban Status

This study uses new Medicare Advantage (MA) encounter data from the Centers for Medicare & Medicaid Services (CMS) combined with Medicare Fee-for-Service (FFS) data and publicly available data on home health agencies. We examine differences in home health care use, including services within home health episodes, and receipt of care from high-quality home health agencies, comparing beneficiaries enrolled in MA versus FFS by rural-urban status and geographic region. Analyses also examine intra-rural variation and differences by MA plan type. Results have important policy implications as MA enrollment grows and MA plans explore greater flexibility in offering home-based services than the FFS program. In addition, incentives for serving rural FFS beneficiaries will decrease and sunset in three years, and a new FFS home health payment system started in CY2020. Understanding baseline differences in home health care between MA and FFS beneficiaries across the rural-urban continuum will help inform future policy initiatives for both programs from the perspective of rural beneficiaries and providers, a key component of CMS’s rural health strategy.

Lead researcher

Tracy Mroz, PhD

aging allied health professionals health disparities and health equity health services Healthcare access healthcare financing Home health Medicare medicare advantage Post-acute Care
In Progress HRSA 2020-10-23"
Treatment, Provider, and Cost Differences for Rural and Urban Patients with Opioid Use Disorder Across the U.S. This study uses health care claims data to (1) describe the workforce that is caring for rural...
Treatment, Provider, and Cost Differences for Rural and Urban Patients with Opioid Use Disorder Across the U.S.

This study uses health care claims data to (1) describe the workforce that is caring for rural (including large rural, small rural and isolated small rural) versus urban populations with OUD, treatments received, (including medication and cognitive therapy) and retention in treatment (duration); (2) explore regional differences in care for urban and rural patients; (3) compare the care received by patients living in counties with and without Drug Enforcement Agency (DEA)-waivered providers; (4) compare the distance and time that patients from large, small and isolated small rural places travel for opioid use disorder (OUD) care compared to urban patients and (5) compare the cost of treatment for patients with OUD from rural and urban areas. Analyses will also compare nurse practitioner (NP) prescribing practices in states that require NP supervision by physicians with those that allow NPs to prescribe autonomously. Findings from this study can be used to improve national and state policies regarding the DEA waiver to prescribe buprenorphine and scope of practice, which could improve access for rural and other disadvantaged populations. Our analysis will also provide helpful insights about where and from whom rural patients with OUD receive care (such as psychosocial support) in the absence of a comprehensive OUD treatment workforce in their local communities.

Lead researcher

C. Holly A. Andrilla, MS

behavioral health Health Services Healthcare access healthcare financing Mental health Nurse and nurse practitioners physician assistants Substance use and treatment telehealth
In Progress HRSA 2020-10-23"
Impact of COVID-19 on Cancer-Related Health Behaviors in Rural Cancer Patients and Rural Cancer Survivors The COVID-19 global pandemic has had an unprecedented impact on the lives of almost every resident...
Impact of COVID-19 on Cancer-Related Health Behaviors in Rural Cancer Patients and Rural Cancer Survivors

The COVID-19 global pandemic has had an unprecedented impact on the lives of almost every resident of the United States. The subsequent public health mitigation strategies, including social distancing measures, are effectively reducing transmission of the COVID-19 virus, but may have negative impact on behaviors important for cancer patients and cancer survivors (e.g., adhering to cancer treatment or cancer surveillance, physical activity, healthy diet, or alcohol consumption). Because rural cancer patients and rural cancer survivors already have significant barriers to accessing cancer care and engaging in healthy behaviors, the impact of COVID-19 social distancing measures may be even more pronounced in these settings. The purpose of this study is to conduct a cross-sectional survey of 800 (400 rural, 400 non-rural) cancer patients and cancer survivors in Washington state to measure non-adherence to cancer care and explore the degree to which COVID-19 social distancing measures are associated with non-adherence to cancer care and unhealthy cancer-related health behaviors for rural and non-rural participants. The results of this study will be critical in helping understand the potentially negative health impact of COVID-19 for rural cancer patients (a particularly vulnerable group) and provide guidance to public health professionals and policy makers to develop strategies to reduce the negative health impact.

Lead researcher

Allison Cole, MD, MPH

In Progress National Cancer Institute 2020-09-05"
The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S. Monitoring the rural and urban supply and distribution of clinicians who provide obstetrical (OB)...
The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S.

Monitoring the rural and urban supply and distribution of clinicians who provide obstetrical (OB) services is important for identifying areas that may lack access to OB care and identifying solutions. This brief describes the supply and geographic distribution of four types of OB care clinicians – obstetricians, advanced practice midwives, midwives (not advanced practice), and family physicians – using data from the 2019 National Plan and Provider Enumeration System and the American Board of Family Medicine. We provide estimates of each clinician type per 100,000 women of child-bearing age (15 through 49 years), describing supply and distribution for rural versus urban counties and among rural counties, micropolitan versus non-core counties. Our findings reveal that significant disparities exist between rural and urban areas in the supply of clinicians who provide OB services.

Lead Researcher: Davis Patterson PhD
Contact:   206-543-1892

Healthcare access Maternal Health Physicians workforce
Complete HRSA 2018-10-17"
The Supply and Distribution of the Primary Care Health Workforce in Rural America Chronic and sometimes severe shortages of primary care providers in rural areas of the U.S. have...
The Supply and Distribution of the Primary Care Health Workforce in Rural America

Chronic and sometimes severe shortages of primary care providers in rural areas of the U.S. have challenged rural communities for decades. Primary care shortages especially threaten health and healthcare in rural communities in part because rural populations depend on primary care providers in ways that urban populations do not. Rural primary care providers deliver a wider range of medical services than their urban counterparts, coordinate care that must be obtained in other locations, and have an essential role in connecting patients to specialty services that are unavailable locally. The geographic maldistribution of primary care providers across rural areas creates particularly acute shortages in some regions and some types of rural areas, while other rural areas are relatively well supplied.

This study examines the 2019 supply and geographic distribution of primary care physicians, nurse practitioners, and physician assistants across rural areas of the U.S. We used 2019 primary care provider data from National Plan and Provider Enumeration System linked to county-level Urban Influence Codes and 2019 Claritas population data to calculate provider-to-population ratios for each provider type in all U.S. non-metropolitan counties. We compared supply between metropolitan, micropolitan, and non-core counties for each provider types. Findings are presented in a series of national maps, tables, and charts. (Individual state-level analyses are also available.) Nationally, the provider-to-population ratio of family physicians is slightly higher in rural than urban areas, but the overall per capita supply of primary care providers remains substantially lower in rural areas than urban areas. About 5% of rural counties, mostly non-core counties, have no family physicians. Maldistribution of primary care providers continues to exacerbate primary care provider shortages in some rural areas, especially in more remote non-core counties.

Lead Researcher: Eric H. Larson, PhD
Contact:  206-616-9601

nurse practitioners physician assistants Physicians workforce
Complete HRSA 2018-10-17"
Understanding the Prescribing Practices of Rural Nurse Practitioners and Physician Assistants with a DEA Waiver to Prescribe Buprenorphine The United States is in the midst of a severe and tragic opioid abuse epidemic. In 2015 more than 2...
Understanding the Prescribing Practices of Rural Nurse Practitioners and Physician Assistants with a DEA Waiver to Prescribe Buprenorphine

The United States is in the midst of a severe and tragic opioid abuse epidemic. In 2015 more than 2 million Americans suffered from pain reliever disorder and more than half a million were using heroin. In 2016, an estimated 42,249 Americans died of an opioid drug overdose. Data suggest that rural areas are disproportionately impacted. Both death rates and non-medical use of prescription drugs have been rising more rapidly in rural than urban areas. The most effective treatment options for opioid use disorder (OUD) include buprenorphine-naloxone, a medication differing from methadone in that office-based physicians, nurse practitioners (NPs) and physician assistants (PAs) with a Drug Enforcement Administration (DEA) waiver can prescribe it. Several recent WWAMI RHRC studies have found a paucity of physicians located in rural areas who have a DEA waiver to prescribe buprenorphine as an office-based outpatient treatment for OUD and a relatively low percentage of physicians with a waiver who are prescribing, as well as described the barriers physicians report in providing this service. More than half of rural US counties (and 44% of all counties) lack even a single waivered provider. Additionally, the presence of a provider who has obtained a DEA waiver in a county does not necessarily mean that buprenorphine treatment is available there. In a recent national survey of rural physicians with a DEA waiver, more than half (53%) of physicians with the initial 30-patient waiver reported they were not treating any patients. No study has looked at the prescribing patterns of NPs and PAs in rural America who obtained a DEA waiver as allowed under the Comprehensive Addiction and Recovery Act. Other treatment options such as Opioid Treatment Centers are available in urban areas but are not readily available in rural locations. This study will extend our past work, describing the availability of office-based outpatient treatment for OUD in rural areas by surveying all rural NPs and PAs with a DEA waiver to prescribe buprenorphine. The survey will seek to quantify the number of rural NPs and PAs currently providing treatment, the number of patients being treated, and factors that facilitate or discourage these providers from offering treatment.
Lead Researcher: Holly Andrilla, MS
Contact Info: hollya@uw.edu, 206-685-6680

Nurse and nurse practitioners physician assistants Substance use and treatment
Complete HRSA 2018-10-17"
Post-acute Care Quality for Rural Medicare Beneficiaries Over one-third of Medicare beneficiaries are discharged to post-acute care following inpatient...
Post-acute Care Quality for Rural Medicare Beneficiaries

Over one-third of Medicare beneficiaries are discharged to post-acute care following inpatient hospitalization, with initial post-acute care services provided by skilled nursing facilities and home health agencies about 80% of the time. Post-acute care is also a key driver of geographic variation in Medicare spending. Due to wide geographic variation in utilization, costs, and quality of post-acute care for Medicare beneficiaries, CMS is implementing value-based purchasing programs for skilled nursing facilities and home health agencies to incentivize high quality, efficient care. The skilled nursing facility value-based purchasing program started in 2017 and includes all Medicare-certified skilled nursing facilities across the country. The home health value-based purchasing demonstration started in 2016 and includes all Medicare-certified home health agencies in nine states. A nationwide home health value-based purchasing program is slated to launch by 2022. Both value-based purchasing programs include rural providers. Yet little is known about quality of care specifically among rural post-acute care providers and with respect to urban providers. Since rural post-acute care providers face unique challenges in delivering care and rural post-acute patients are often sicker and at higher risk for poor outcomes, rural providers may be at greater risk for penalties under value-based purchasing programs. Rural post-acute care providers that have Medicare payments substantially decreased for poor performance may not have the resources necessary to implement quality improvement initiatives to avoid further penalties. While high-quality care must remain a key goal for all providers, reductions in payments may disproportionately impact some rural providers, which in turn may exacerbate disparities for rural beneficiaries.
Lead Researcher: Tracy Mroz, PhD
Contact Info: tmroz@uw.edu, 206-598-5396

Home health Post-acute Care
Complete HRSA 2018-10-17"
What Are Best Practices for Providing Buprenorphine Maintenance Treatment in Rural Primary Care? Not all physicians with a Drug Enforcement Agency waiver to prescribe buprenorphine actually...
What are Best Practices for Providing Buprenorphine Maintenance Treatment in Rural Primary Care?

Not all physicians with a Drug Enforcement Agency waiver to prescribe buprenorphine actually provide this treatment or fully utilize their waiver capacity. This project will interview physicians successfully using their waivers to identify best practices for prescribing buprenorphine treatment for Opioid Use Disorder.

Complete HRSA 2018-04-20"
Do Rural Breast and Colorectal Cancer Patients Present at More Advanced Disease Stages than their Urban Counterparts? This project will use the Surveillance, Epidemiology and End Results Program (SEER) data set to...
Do Rural Breast and Colorectal Cancer Patients Present at More Advanced Disease Stages than their Urban Counterparts?

This project will use the Surveillance, Epidemiology and End Results Program (SEER) data set to examine the extent to which rural residents present at more advanced disease stages for breast and colorectal cancer diagnosis when compared to urban residents.

In Progress HRSA 2018-04-20"
Who Provides Mental Health Services to Rural Medicare Beneficiaries? This study described the provider workforce that cares for rural elderly patients with...
Who Provides Mental Health Services to Rural Medicare Beneficiaries?

This study described the provider workforce that cares for rural elderly patients with depression/anxiety. It also described regional and rural-urban variation in mental health care provision.

Complete HRSA 2018-04-20"
Post-Acute Care Trajectories for Rural Medicare Beneficiaries This study examined post-acute care utilization for rural Medicare beneficiaries following acute...
Post-acute Care Trajectories for Rural Medicare Beneficiaries

This study examined post-acute care utilization for rural Medicare beneficiaries following acute hospitalization. Post-acute care services help patients transition from hospitalization in acute care facilities to their homes. Post-acute care services include skilled nursing, rehabilitation, and medical social work services designed to help patients maximize their functional abilities and return safely to community living. Skilled nursing facilities and home health agencies provide the vast majority of post-acute care services to Medicare beneficiaries. Yet, post-acute care services for rural Medicare beneficiaries specifically have not been well documented, despite the unique challenges of providing post-acute care in rural communities and possible limitations accessing these services. Even less is known about whether rural Medicare beneficiaries with planned discharges to post-acute care providers actually receive those services. This project uses Medicare administrative data to describe the most common types of care trajectories among rural beneficiaries following discharge from acute hospitalization and compares planned versus actual discharges to skilled nursing facilities and home health agencies following acute hospitalization.

Complete HRSA 2018-04-20"
Increasing the Supply of Providers with a Drug Enforcement Agency Waiver to Treat Opioid Addiction in Rural America – Possible Effects of Permitting Physician Assistants and Nurse Practitioners to Prescribe Buprenorphine This study will investigate the possible effects on rural access to treatment for opioid use...
Increasing the Supply of Providers with a Drug Enforcement Agency Waiver to Treat Opioid Addiction in Rural America – Possible Effects of Permitting Physician Assistants and Nurse Practitioners to Prescribe Buprenorphine

This study will investigate the possible effects on rural access to treatment for opioid use disorder if Drug Enforcement Administration (DEA) waivers to prescribe buprenorphine as an office-based outpatient treatment for opioid addiction were available to Physician Assistants (PAs) and Nurse Practitioners (NPs). Better understanding of the potential additional workforce available to treat the devastating opioid use epidemic will allow policy makers to make informed decisions on expanding waiver eligibility.

Complete HRSA 2018-02-03"
Geographic Access to Health Care for Rural Medicare Beneficiaries: An Update and National Look Rural residents generally use fewer medical services, travel farther for care and often have more...
Geographic Access to Health Care for Rural Medicare Beneficiaries: An Update and National Look

Rural residents generally use fewer medical services, travel farther for care and often have more problems accessing medical and surgical specialists than their urban counterparts. These issues can be particularly problematic for older rural Medicare beneficiaries who need specialist services or for whom long travel distances may pose challenges. This objective of this study is to compare, at a national and census division level, where rural and urban Medicare beneficiaries receive ambulatory care, which types of specialists they utilize and how far beneficiaries are traveling to obtain care. In addition to rural/urban comparisons, intra-rural variation in utilization and travel distance will be evaluated and compared.

In Progress HRSA 2018-02-03"
Assessing Potential Unmet Need for Home Health Care in Rural Areas This study will estimate potential unmet need for home health care in rural areas for...
Assessing Potential Unmet Need for Home Health Care in Rural Areas

This study will estimate potential unmet need for home health care in rural areas for fee-for-service Medicare beneficiaries. We will compare rates of home health care utilization in rural areas with urban areas, accounting for acute hospital discharges and utilization of inpatient rehabilitation facilities and skilled nursing facilities. We will examine intra-rural variation in transition from hospital to different post-acute care providers and quantity of home health care services by diagnostic group. Findings from this study will help inform policies addressing access to and reimbursement of rural home health care and adequacy of home health care workforce supply.

Complete HRSA 2018-02-03"
Prehospital Emergency Medical Services Personnel: Comparing Rural and Urban Provider Experience and Provision of Evidence-based Care This study will describe the relationship between prehospital emergency medical services (EMS)...
Prehospital Emergency Medical Services Personnel: Comparing Rural and Urban Provider Experience and Provision of Evidence-based Care

This study will describe the relationship between prehospital emergency medical services (EMS) providers’ accumulated experience and provision of evidence-based care for rural and urban populations using newly available data on EMS agencies, workforce, and patient care. Results will inform policies for ensuring that rural populations have timely and appropriate access to high-quality prehospital emergency care.

In Progress HRSA 2018-02-03"
Rural Physician Residencies under Unified Accreditation The impending unification in 2020 of allopathic and osteopathic graduate medical education (GME)...
What Impact Will Unified GME Accreditation Have on Rural-focused Physician Residencies?

The impending unification in 2020 of allopathic and osteopathic graduate medical education (GME) under a single accreditation system has uncertain implications for small and rural-focused residency programs. This study quantified the availability of rural-centric residency training (required rural training of at least 8 weeks) in the rurally-relevant specialties of pediatrics, internal medicine, obstetrics/gynecology, emergency medicine, surgery, anesthesia, and psychiatry. Findings include the distribution of rural vs. urban training locations and rural-specific content of rural-centric residency programs.

Complete HRSA 2015-11-30"
Rural Home Health Services for High Risk Patients This study will examine outcomes of care for rural Medicare patients who were discharged from...
Use of Home Health Services among High Risk Rural Medicare Patients: Patient, Service, and Community Factors Associated with Outcomes of Care

This study will examine outcomes of care for rural Medicare patients who were discharged from hospitals and admitted to home health care for post-acute services. Outcomes will include emergent care use and re-hospitalization during the home health admission and community discharge. Key predictors include type of rural community (large, small, isolated small), geographic region, types and amounts of home health services provided, home health agency workforce characteristics, and available community health care resources.

Complete HRSA 2015-11-30"
Rural Behavioral Health Workforce Data from the National Plan and Provider Enumeration System (NPPES) file, linked to RUCA codes and...
Supply and Distribution of the Behavioral Health Workforce in Rural America

Data from the National Plan and Provider Enumeration System (NPPES) file, linked to RUCA codes and population data, will be used to identify behavioral health providers and describe their geographic (rural/urban, regional and intra-rural) distribution. Behavioral health professions identified in the file include psychiatrists, addiction medicine specialists, psychiatric nurse practitioners, clinical nurse specialists in mental health, clinical psychologists and licensed social workers.

Complete 2015-11-30"
Programs Producing Rural PAs: Part 2 This study builds on a previous WWAMI RHRC study that identified the physician assistant (PA)...
What Makes Physician Assistant Programs Successful at Training Rural PAs?

This study builds on a previous WWAMI RHRC study that identified the physician assistant (PA) training programs that have produced high numbers and high proportions of graduates working in rural areas. This study will extend that work through a physician assistant program survey, identifying key characteristics, admission and training strategies, and missions of successful rural programs.

Complete 2015-11-30"
Post-acute vs. Community-entry Home Health in Rural Areas Medicare beneficiaries may be admitted to home health following an inpatient stay (post-acute) or...
Diverging Populations Served by the Medicare Home Health Benefit: Comparison of Post-acute vs. Community-entry Home Health in Rural Areas

Medicare beneficiaries may be admitted to home health following an inpatient stay (post-acute) or directly from the community (community-entry). An analysis of Medicare data for rural, fee-for-service Medicare beneficiaries who utilized home health from 2011 to 2013 found significant differences in care processes between community-entry and post-acute home health. Compared to post-acute home health episodes, community-entry home health episodes on average were longer; less likely to include physical, occupational, and speech therapy visits; more likely to include medical social work visits; and less likely to be initiated on the physician-ordered start date or within two days of referral. Results suggest community-entry and post-acute home health are serving different needs for rural Medicare beneficiaries, which provides preliminary support for distinguishing between the two types of episodes in payment policy reform.
Lead Researcher: Tracy Mroz

Complete HRSA 2015-11-30"
Community Paramedicine Evidence Community paramedicine (CP) has been promoted as a strategy to help communities achieve the Triple...
What Is the Potential of Community Paramedicine to Fill Rural Healthcare Gaps?

Community paramedicine (CP) has been promoted as a strategy to help communities achieve the Triple Aim of improving healthcare and population health while lowering costs. This study is collecting descriptive information on CP programs that can be identified in the U.S., and for those programs with outcome data, comparing rural with urban programs in terms of their goals, services offered, outcomes measured, and results.

Complete 2015-11-30"
Availability of Buprenorphine Services in Rural Areas This study will investigate the extent to which physicians who practice in rural areas and have a...
Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas

This study will investigate the extent to which physicians who practice in rural areas and have a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine as an office-based outpatient treatment for opioid use disorder are providing this treatment to their patients. This study will also estimate the need for office-based opioid disorder treatment in rural locations.

Complete 2015-11-30"
Rural Physician Assistants Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in...
National Rural Physician Assistant Content of Care Study

Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in primary care settings serving rural and other underserved populations. By the 1990s, PAs were practicing in a much wider variety of settings in many medical specialties. Aim: To describe the demography, practice arrangements and content of practice of a nationally representative sample of PAs collected in the 1990s. Methods: A stratified random sample of PAs was surveyed in 1993-1994. The demography, practice characteristics and content of PA practice were analyzed across practice location and medical specialty. Results: Of all the living PAs ever trained, 95% were active in the health care delivery system at the time of the survey. Eighty-seven percent of those trained were practicing as PAs, nearly all of whom were practicing full time. Rural PAs were more likely to be white and male than their urban counterparts and had lower levels of education prior to entering PA training. Generalist PAs performed many more outpatient visits than specialist PAs, and fewer inpatient visits. In urban areas, PAs were making a large contribution to surgical care. About three-fourths of the rural PAs were generalists. Conclusions: The broader scope of practice of generalist PAs, especially those serving rural populations, points to the need to ensure that training programs, especially those emphasizing generalist care for rural and underserved populations, provide sufficient breadth in medical training to meet those needs. Funded by HRSA’s ORHP.
Lead Researcher: Eric H. Larson, PhD
Contact Info: ehlarson@uw.edu, 206-616-9601

Complete 2015-10-02"
Unhealthy Lifestyles of Rural/Urban Minorities: Obesity Background: Obesity is on the rise in the United States and has been implicated in serious chronic...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity

Background: Obesity is on the rise in the United States and has been implicated in serious chronic health problems. Obesity is very costly in terms of medical spending and lost productivity. Aim: To estimate the prevalence of and recent trends in obesity among U.S. adults residing in rural and urban locations. Methods: A telephone survey of adults aged 18 years and older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS) in 1994-1996 and 2000-2001. The main outcome measure for the study was obesity, defined as a body mass index of 30 or greater, based on self-report. Results: In 2000-2001, the prevalence of obesity was 23.0% for rural adults and 20.5% for their urban counterparts, increases of 4.8% and 5.5%, respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties of Mississippi, Texas and Louisiana. Only Rhode Island and Colorado had rural counties that met the HealthyPeople 2010 goal of a maximum of 15% obese for adults. Conclusions: Despite recent attention to the prevalence of obesity, obesity rates continue to rise across the United States and differentially affect inhabitants of rural and urban areas. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Unhealthy Lifestyles of Rural/Urban Minorities: Cigarettes Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim:...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking

Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim: To estimate the prevalence of and recent trends in smoking among adults residing in three types of rural locations. Methods: Telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 and 2000-2001. Results: The prevalence of smoking changed little from the mid-1990s; it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural non-adjacent areas, and 24.9% in small rural non-adjacent areas. For rural locations combined, its prevalence was not below the 12% goal of HealthyPeople 2010 for any state. Its prevalence was ≥ 28% for rural residents of Kentucky, Ohio and Indiana. Since the mid-1990s, the prevalence of smoking for rural respondents decreased by more than 2% in California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2% or more in Alabama, Delaware, Georgia, Massachusetts, Michigan, Mississippi, New Hampshire, Oklahoma, South Carolina, and Texas. Conclusions: Smoking remains a refractory public health problem. Better ways to curb smoking in rural America are needed. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Unhealthy Lifestyles of Rural/Urban Minorities: Alcohol Use Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural...
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use

Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural areas. Methods: A telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS), in the years 1995/1997 and 1999/2001. Results: Urban counties led rural counties for moderate and heavy drinking in 1999/2001, and also saw the largest increases in heavy drinking between 1995/1997 and 1999/2001. Binge drinking was nearly as high in remote rural counties with a large town as in urban counties, and increased the most for remote rural counties with a large town. Urban whites were more likely than any other racial/ethnic group to report moderate or heavy drinking, while American Indians in remote rural counties with a large town were the most likely to report binge drinking. Significant increases in heavy and binge drinking were highest for rural residents in the Northeast and Midwest and lowest in the South Census region. Conclusions: Heavy drinking was highest and increased the most in urban counties; however, binge drinking increased the most in remote rural counties with a large town, and heavy and binge drinking increased for rural counties of all types. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Trends in Rural Perinatal Care of American Indians While there have been dramatic improvements in AI/AN maternal and child health since these measures...
National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)

While there have been dramatic improvements in AI/AN maternal and child health since these measures were first recorded in the mid-1950s, significant disparities persist between AI/AN and non-AI/AN populations in the United States. This study (1) examined trends in prenatal care use, low-birthweight rate, and the neonatal and postneonatal mortality rates in rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends in the white populations during the same time period; (2) examined trends in causes of death for rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends to the white population during the same time period; and (3) analyzed trends in our study measures for AI/AN and white populations by Census region, division, and Indian Health Service (IHS) Service Areas. The study used the National Linked Birth Death Data Set at three points in time: 1985-1987, 1989-1991, and 1995-1997, and compared rates of inadequate prenatal care, low birthweight, neonatal and postneonatal death, and causes of death between rural AI/ANs and Caucasians in each of the three time periods, as well as over time. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Trends in Rural Perinatal Care Little is known about long-term national trends in birth outcomes and use of prenatal care in the...
Changes in U.S. Rural Perinatal Care During the Last Decade

Little is known about long-term national trends in birth outcomes and use of prenatal care in the rural population of the United States, or about intrarural differences in adverse outcome and inadequate prenatal care. In this two-year study, we examined: (1) How have rates of adverse birth outcome and prenatal care among U.S. rural residents changed in the years between 1985-1987 and 1995-1997? and (2) How have adverse birth outcomes and prenatal care changed during these periods among rural residents from racial and ethnic minority groups? We examined data from the Linked Birth Death Data Set (LBDDS), a national compilation of birth certificate data from all 50 states and the District of Columbia. We assessed inter-decade changes in rural/urban and intrarural differences in the rate of low birthweight outcome, neonatal death, postneonatal mortality, and inadequate prenatal care. We also assessed the degree to which observed changes were concentrated in particular types of rural settings or regions. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Trends in Rural Dentistry This study used secondary data sources such as the Area Resource File, American Dental Association...
Rural Dentistry: Availability, Practice, and Access

This study used secondary data sources such as the Area Resource File, American Dental Association data, and state-level professional licensure data to describe the supply of dental providers in several states, with particular attention to the supply of providers in rural areas. Surveys were administered to rural dentists in California, Maine, Missouri, and Alabama to describe the rural dental provider population in those states with respect to demography, practice characteristics, practice satisfaction, use of dental hygienists, Medicaid and CHIP practices, and attitudes towards the use of alternative sources of dental care such as using medical providers to apply sealants in the pediatric population. The study elucidates, from the dental provider perspective, the barriers to access to dental care for rural residents and what can be done to promote rural dental practice. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Tort Reform & Obstetrical Access As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of...
Tort Reform and the Obstetrical Access Crisis

As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of this study had modified the existing tort and/or professional liability systems in their states. This project reviewed recent studies of physicians’ obstetrical practices and major changes in tort legislation and regulation. The majority of general and family physicians in the WAMI region no longer provided obstetrical care, while over 80% of the obstetrician/gynecologists in this area still practiced obstetrics. Most rural family physicians in all four states continued to deliver babies. The majority of physicians in these states limited the amount of care they provide to Medicaid patients. All four states adopted tort reforms, yet the cost of malpractice premiums and concerns over liability continued to limit the number of physicians willing to provide obstetrical care.

Complete 2015-09-25"
The WWAMI Rural Health Workforce This project compiles and presents state-level information about the rural health workforce in the...
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho

This project compiles and presents state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. Information was derived from the American Medical Association Masterfile, the National Sample Survey of Registered Nurses, the Area Resource File, and other sources. This series of policy briefs describes WWAMI rural health workforce challenges and opportunities, workforce numbers, resources, the importance of rural definitions, and tools for workforce policymakers and planners.

Complete 2015-09-25"
The Walkability Project This study is identifying built environmental correlates of walking in rural towns and evaluating...
Small Town Walkability: Measuring the Effect of the Built Environment

This study is identifying built environmental correlates of walking in rural towns and evaluating the role of low socioeconomic status (SES) and Latino ethnicity on these relationships. By studying 9 rural towns from 3 diverse regions, Washington State, the Northeast, and Texas, with a varying range of socioeconomic and ethnic characteristics, this study is: (1) measuring built environmental correlates of walking among small town residents, using objective and perceived measures of the built environment and self-reported measures of walking; (2) evaluating the degree to which built environmental correlates of walking among rural town residents are influenced by SES and Latino ethnicity; and (3) validating the perceived correlates of walking using accelerometer and global positioning system measures. The study will first involve a survey of 1,800 residents of these towns on physical activity patterns and attributes of their towns that promote or impede walking, and will next recruit a sample of 270 respondents who agree to wear two small devices measuring their physical activity for 7 consecutive days. Objective measures of their physical activity will be compared to self-reported data. This work will lay the foundation for future research on the relationship between various aspects of the rural built environment and health behaviors and, ultimately, intervention trials to help rural towns better structure the built environment to promote walking and healthier life styles among their highest risk residents.

Complete 2015-09-25"
Surgical Procedures in Rural This report addresses rural/urban differences in surgical practices in commonly performed inpatient...
General and Specialist Surgeon Supply and Inpatient Procedural Content: A National Rural-Urban Study

This report addresses rural/urban differences in surgical practices in commonly performed inpatient surgical procedures that are typically handled by general surgeons. National Inpatient Sample data from rural and urban hospitals in 24 states were used to examine the frequency of general surgical procedures, complications during hospitalizations and predicted resource demand.
Findings indicate that rural hospitals concentrated on relatively common, low complexity procedures that can be handled by general surgeons, especially if they have received additional training in obstetrics/gynecology and orthopedics. Resource demand, length of stay, complication rates and mortality were lower for patients undergoing common procedures in rural hospitals. Rural training tracks for general surgery that provide a high case load for common general surgery, obstetrics/gynecology and orthopedics procedures may help sustain the general surgery workforce in rural areas.

Complete 2015-09-25"
Surgery in Rural/Urban Hospitals Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were...
Surgical Outcomes of Rural and Urban Hospitals

Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were used in an analysis of readmission rates for four selected conditions by patient residential and hospital location. During the two-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals. No evidence of low-quality care in Washington State rural hospitals was found when investigating readmission rates following common surgeries.

Complete 2015-09-25"
Supply and Retention of Rural Surgeons Background: General surgeons form a crucial component of the medical workforce in rural areas of...
Distribution and Retention of General Surgeons in Rural Areas of the U.S.

Background: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. Aim: To determine the numbers, characteristics, and distribution of general surgeons currently practicing in the rural United States. Methods: The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their location and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas (RUCAs). Results: Nationally, the number of general surgeons per 100,000 population varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation’s general surgeons were female. General surgeons in the smallest rural areas were more likely than those in urban areas to be male (92.7% versus 88.3%), 50 years of age or older (51.6% versus 42.1%), or international medical graduates (25.2% versus 20.1%). Conclusions: The overall size of the rural general surgical workforce has remained static, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. This project was funded by HRSA’s FORHP, with the publication Thompson et al. 2005 and Final Report #77 as deliverables.

Complete 2015-09-25"
State Rural Health Workforce Monograph The uneven distribution of health care providers across rural and urban areas of the United States...
State Rural Health Workforce Monograph

The uneven distribution of health care providers across rural and urban areas of the United States continues to impede access to care for millions of rural residents. This book profiles that workforce with comparisons of the supply of health professionals across the 50 states and within the rural areas of each state. In addition to individual state workforce profiles, the book includes discussion of key policy and methodological issues in workforce analysis. The data and analysis show that the nature and magnitude of rural health workforce problems vary substantially both across states and within them, suggesting the dangers of “one-size-fits-all” policy solutions. This book provides a picture of the rural health workforce that will serve analysts and policy makers well as they search for workable solutions to the problem of inadequate supply of health care providers in rural America. Funded by HRSA’s FORHP.

Complete 2015-09-25"
Staffing of Rural Hospital ERs All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how...
Physician Staffing of Small Rural Hospital Emergency Departments

All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how rural emergency departments were staffed by physicians and to estimate rural hospital payments for these services. Study data were collected through telephone interviews with hospital administrators or directors of nursing services. Results indicated that 86% of rural hospitals contracted for emergency department coverage and 59% obtained some or all of this service from nonlocal physicians.

Complete 2015-09-25"
Specialty Care for Rural American Indians Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native...
Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)

Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native (AI/AN) health services is less than half that spent per year on the U.S. civilian population. Many AI/ANs, especially in rural areas, depend on the IHS as their only source of funding for health care. Specialty services may be limited by a low level of contract funding. Aim: To examine access to specialty services among rural AI populations. Methods: A mail survey addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services was sent to primary care providers in rural Indian health clinics in Montana and New Mexico and primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics. Results: Substantial proportions of rural Indian clinic providers in Montana and New Mexico reported fair or poor access to nonemergent specialty services for their patients. Montana’s rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico’s rural Indian and non-Indian providers reported comparable access. Indian clinic providers in most frequently cited financial barriers to specialty care. Indian clinic providers in both states reported better access to several nonphysician services than non-Indian clinic providers. Conclusions: Access to specialty care for rural Indian patients is limited, and is influenced by the organization of care systems and financial constraints. Funded by HRSA’s FORHP.

Complete 2015-09-25"
Rural/Urban Obstetrical Care Quality Washington State vital statistics data from 1984 through 1988 were used to investigate differences...
Quality of Obstetrical Care Provided to Rural Versus Urban Residents

Washington State vital statistics data from 1984 through 1988 were used to investigate differences in the process and outcome of obstetrical care based on the rural/urban locations of the mothers’ residences. This study compared rural and urban obstetrical care in terms of mortality, trimester prenatal care began, adequacy of the number of prenatal visits, and birthweight. Separate analyses (1) differentiated between rural mothers who delivered in rural locations and those that delivered in urban locales and (2) partitioned low and non-low risk women.

Complete 2015-09-25"
Rural/Urban Generalists This two-year project used Medicare data provided by HCFA to describe the content of practice of...
Who Are the Generalists in Rural and Urban Areas?

This two-year project used Medicare data provided by HCFA to describe the content of practice of physicians in rural and urban areas of Washington State. The population studied included board-certified physicians in the 12 largest ambulatory medical specialties in Washington State who were in active medical practice in 1994 and who provided ambulatory care to at least ten Medicare patients per year during that period. The diagnostic and procedural breadth of rural and urban physicians in all specialties was found to be similar, with the exception of rural general surgeons and obstetrician-gynecologists, who were more likely to care for patients outside their specialty area. Funded by HRSA’s ORHP.

Complete 2015-09-25"
Rural U.S. Perinatal Health This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth...
Perinatal Health in the Rural United States, 2005

This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth weight, a key indicator of the health of the U.S. population, and adequacy of prenatal care, a critical indicator of access and quality of health care, were explored to discover how they are related to rural or urban location, race, and ethnicity.

Complete 2015-09-24"
Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...
Factors Associated with Rural-Residing Registered Nurses’ Choices to Work in Urban Locations and Larger Rural Cities

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

Complete 2015-09-24"
Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...
Factors Associated with Rural-Residing Registered Nurses' Choices to work in Urban Locations and Larger Rural Cities

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

Complete 2015-09-24"
Rural Physicians Waivered to Treat Opioid Addiction Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and...
The Supply of Physicians Waivered to Treat Opioid Addiction in Rural America: Policy Options to Remedy Critical Shortages

Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and 2007, and opiate misuse among adolescents is now twice as common as in the 1990s. Because methadone maintenance clinics are largely non-existent in rural areas, an effective alternative is training physicians in the use of buprenorphine, an effective addiction treatment that can be administered in outpatient practices. This study will determine the extent to which a trained workforce exists in rural America that has received the necessary waiver to treat opioid addiction in outpatient settings with buprenorphine, identifying areas with critical shortages and discussing policy options for expanding the supply of these qualified providers. Funded by HRSA’s Office of Rural Health Policy.

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Rural Physician, NP, PA Impact This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs),...
What Are the Possible Impacts of Nurse Practitioners and Physician Assistants on Future Provision of Primary Care in Rural Areas?

This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs), and physicians will be required to meet rural health care demand resulting from expanded access to health insurance through implementation of the Affordable Care Act (ACA). The study will also describe the ACA’s impact on types of primary care services that would be available under different provider mix scenarios. The study’s analyses will use simulated rural primary care demand data and rural primary care NP, PA, and physician productivity data from recent research by the WWAMI RHRC. Funded by HRSA’s Office of Rural Health Policy.

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Rural Pediatric Inpatient Care This study described the distribution of rural practitioners in Washington State who provide...
Pediatric Inpatient Care in Rural Hospitals

This study described the distribution of rural practitioners in Washington State who provide inpatient care to pediatric patients, elucidated the major diagnostic categories for which children are hospitalized in rural versus urban areas, contrasted the roles of pediatricians and family physicians providing pediatric care, and assessed the effectiveness of the system. The major source of data for this study was CHARS, which was linked to information on the training and discipline of the providers who cared for each of the patients in the study. Funded by HRSA’s ORHP.

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Rural Oral Health Challenges This review identifies the challenges to oral health in rural America and describes areas of...
Oral Health Services in Rural America

This review identifies the challenges to oral health in rural America and describes areas of innovation in prevention, delivery of dental services, and workforce development that may improve oral health for rural populations. This paper was part of a special issue of the Journal of Public Health Dentistry. The purpose of the special issue was to further develop ideas presented at the 2009 Institute of Medicine (IOM) workshop, “The Sufficiency of the U.S. Oral Health Workforce in the Coming Decade.” Using the IOM discussions as their starting point, the authors evaluate oral health care delivery system performance for specific populations’ needs and explore the roles that the workforce can play in improving the care delivery model. The contributing articles provide a broad framework for stimulating and evaluating innovation and change in the oral health care delivery system. The articles in this special issue point to many deficits in the current oral health care delivery system and provide compelling arguments and proposals for improvements.

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Rural Obstetrical Technology This study compared the approach to neonatal care in Wales and Washington State, studying the...
A Comparison of Obstetrical Technology at Rural Hospitals in Washington and Wales

This study compared the approach to neonatal care in Wales and Washington State, studying the extent of perinatal regionalization, the distribution of neonatal technologies, and birthweight-specific neonatal outcomes. In Wales, most District General Hospitals (DGH) had all the neonatal equipment recommended for a maximal neonatal intensive care unit, whether or not the DGH was a designated regional or subregional center. Sophisticated neonatal technology in Washington was concentrated in designated referral hospitals. Almost every Welsh DGH cared for infants weighing less than 1,000 grams at birth, while in Washington State most very-low-birthweight neonates were born in referral centers and the few born elsewhere were transferred immediately after birth. Despite differences in the extent of regionalization, birthweight-specific neonatal mortality rates were similar in the two countries.

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Rural NSSNP Analysis This WWAMI RHRC study uses data from HRSA's first National Sample Survey of Nurse Practitioners...
Practice Characteristics of Rural Nurse Practitioners in the United States

This WWAMI RHRC study uses data from HRSA’s first National Sample Survey of Nurse Practitioners (NSSNPs) to expand on the agency’s basic descriptive analyses of rural and urban nurse practitioners (NPs). The study compares rural and urban NPs’ demographics, education, practice, and related characteristics; and estimates basic NP labor supply models. Funded by HRSA’s Office of Rural Health Policy.

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Rural Medicine Textbook This book explores what is known about the content, needs, and special problems of rural health...
FORHP Rural Health Research Center Book and Rural Medicine Textbook

This book explores what is known about the content, needs, and special problems of rural health care. The goal was to advance the knowledge base and describe strategies used by rural health professionals in developing quality of care for rural communities and their residents. The book includes an overview of rural health care, special clinical problems and approaches in rural health care, the organization and management of rural health care, approaches to quality improvement, and education for rural practice.

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Rural Hospital Surgical Capacity This study examined the availability of several elective and urgent surgical procedures at rural...
Surgical Capacity of Rural Washington State Hospitals

This study examined the availability of several elective and urgent surgical procedures at rural hospitals, identified the specialties of rural surgery and anesthesia providers, and determined where rural residents obtained surgical services and how the utilization of services is influenced by the presence of local services. Data were obtained from telephone interviews with hospital administrators, directors of nursing services, and/or operating room charge nurses. Washington State complete hospital discharge data provided the number of selected and aggregate procedures for each hospital by diagnosis and procedure codes, as well as hospital reimbursement for surgical procedures.

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Rural Hospital Project The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through...
Transferability of the Rural Hospital Project

The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through a multifaceted approach to addressing their problems and strengthening health services. Subsequently, the RHP interventions were applied through a Community Health Services Development Model to other rural hospitals throughout the regional Area Health Education Centers (AHECs). This study examined the process of exporting the interventions from a university-based demonstration project to a community-based program disseminated by the AHECs.

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Rural Hospital Linkages Linkage refers to a rural hospital's formal and informal associations with outside entities (e.g.,...
Rural Hospital Linkages in the WAMI Region

Linkage refers to a rural hospital’s formal and informal associations with outside entities (e.g., joint purchasing arrangements and inter-hospital networks). This study (1) provided a descriptive analysis of rural hospital linkages in the WAMI states based on a literature review and key informant interviews, (2) determined how governmental regulations influence such linkages, and (3) performed case studies on two rural health care alliances located in different regions and formed 13 years apart.

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Rural Hospital Governing Boards Part C Background: Little research has been conducted to describe the factors and practices associated...
Characteristics of Rural Hospital Governing Boards. Part C: Which Activities of Small Rural Hospital Boards Are Associated with Success?

Background: Little research has been conducted to describe the factors and practices associated with the effectiveness of rural hospital governing boards. Aim: To identify activities and characteristics of the governing boards of small rural hospitals that are related to hospital success. Methods: We surveyed 89 rural hospital board chairs in Washington, Alaska, and Idaho about how they spent their time and how they were organized. We asked experts familiar with 74 hospitals with less than 100 beds to rate them in several key areas. Results: The eight activities of boards associated with “strong” hospitals included: one or more board retreats per year, annual review of mission and goals, lower percentage of time monitoring budget, use of board committees, clear recruitment plan to attract desirable board members, funds for continuing education of board members, owned or leased ownership, and larger hospital average daily census. In addition, the “strong” hospitals were found to have higher daily census than the “weak” hospitals (higher among hospitals with less than 100 beds). Conclusions: As long as the governance of rural hospitals is in the hands of volunteer boards, researchers and policy makers should assist these boards in identifying the most efficient and effective ways for them to spend their limited time and resources. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part B Background: To provide competent membership, a board member needs knowledge of health care...
Characteristics of Rural Hospital Governing Boards. Part B: An Assessment of the Knowledge of Governing Board Members in Rural Hospitals

Background: To provide competent membership, a board member needs knowledge of health care developments and the organization of the board. Aim: To provide information on the knowledge level of governing board members in hospitals in three northwestern states. Methods: This study included 130 hospitals with individual governing boards in rural areas of Alaska, Idaho, and Washington. As part of a larger survey of all rural hospital board members in these states, we asked board members questions relevant to competent membership on a governing board. This included questions concerning quantifiable aspects of the hospitals, planning, and financial reporting. Results: Knowledge on the part of the board members was strongest in the areas of the role of the governing board, planning, and scope of services. Board members were less able to quantify the capacities and utilization of services at their hospitals. Results were mixed in the area of knowledge of financial management. Length of service on the board and efficient board structures were associated with increased knowledge. Conclusions: While board members were knowledgeable about their roles and the services offered by their hospitals, their knowledge base in certain other crucial areas was limited, underscoring the need for programs that facilitate board member training. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part A Background: Literature about rural health providers has focused largely on physicians, mid-level...
Characteristics of Rural Hospital Governing Boards. Part A: Who Governs Rural Hospitals?

Background: Literature about rural health providers has focused largely on physicians, mid-level providers, and hospitals and their administrators, but little has been written about the boards that govern those hospitals. Aim: To describe the role and composition of rural hospital governing boards. Methods: Hospitals in Washington, Alaska, and Idaho were included in this study. Surveys related to hospital governance were administered to rural hospital board members and board chairpersons of urban and rural hospitals. Results: Board members were typically white males over the age of 50 and retired. They served an average of seven years and most typically brought business and management expertise to their positions. Board members contributed more than a dozen hours per month to board business and attended about 90% of their board and committee meetings. Fewer than one in four rural hospital board chairs indicated his or her board had a formal recruitment program, and fewer than half of the boards spent more than three hours on board member orientation. Board chairs were more likely to rate highly the performance of other community leaders, as well as members of the medical staff. Conclusions: Boards are attracting the service of individuals who are well educated, experienced, and willing to contribute more than a dozen hours a month to their board service. However, small rural boards are not investing enough time and funds in orientation and training. Funded by HRSA’s ORHP.

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Rural Hospital CEO Turnover This study described the tenure, rate of and reasons for turnover of hospital administrators, and...
Administrator Turnover in Rural Hospitals

This study described the tenure, rate of and reasons for turnover of hospital administrators, and tracked the career trajectories of rural hospital administrators. The study was performed in partnership with the WAMI Area Health Education Center and the Washington State Hospital Association. Resumes from all Washington State hospital administrators contrasted the education and professional backgrounds of rural and urban administrators. A survey of all regional rural hospital administrators who left their position during the past three years provided information on hospital characteristics, reasons that they left, effects on the hospital and community, evaluation of their performance, and gaps in training. Questionnaires were sent to a hospital board member in the same community to ascertain why the administrator left, consequences of the departure, and adequacy of the administrator’s performance.

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Rural Hospital Care for Acute Myocardial Infarction: 2000-2001 This project examined whether overall improvements in the quality of care for acute myocardial...
Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?

This project examined whether overall improvements in the quality of care for acute myocardial infarction (AMI) among Medicare patients occurred in both rural and hospital settings. It used the Cooperative Cardiovascular Project Database and a database of measures of clinical performance, and included in the sample those Medicare beneficiaries with an AMI who were directly admitted for AMI care. Funded by HRSA’s ORHP.

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Rural Hospital Anesthesia Services Key to the ability of rural hospitals to maintain a surgery service is the availability of...
The Provision of Anesthesia Services in Rural Hospitals

Key to the ability of rural hospitals to maintain a surgery service is the availability of anesthesia personnel, yet anecdotal evidence indicates that their supply is limited and their salary costs are high. This study surveyed administrators from rural hospitals in Washington and Montana regarding their experience in recruiting and retaining nurse and physician anesthetists. Aspects of anesthesia coverage such as financial arrangements, professionals working at multiple sites, outpatient and inpatient surgery, inter-provider type professional rivalries, and licensure constraints were examined. Funded by HRSA’s ORHP.

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Rural Home Health Care Access to home health care can be challenging for rural Medicare clients. Key informants for this...
Access to Home Care Services in the Rural United States

Access to home health care can be challenging for rural Medicare clients. Key informants for this study from across the U.S. detailed these obstacles, which include financial, regulatory, workforce, and geographic issues, as well as solutions that merit consideration. Rural communities, especially those served by small and non-profit home health agencies, will likely benefit from payment reforms that reward quality services while providing incentives to innovate and use best practices in home health care.

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Rural HIT Workforce Needs The goal of this study is to improve understanding of health information technology (HIT) workforce...
Health Information Technology (HIT) Workforce Needs in Rural America

The goal of this study is to improve understanding of health information technology (HIT) workforce needs and constraints in rural primary care settings. This study will determine rural primary care practices’ current and projected level of electronic health record (EHR) and health information technology (HIT) adoption and estimate demand for workers with HIT skills. This study will survey a stratified sample (large and small rural areas) of approximately 1,600 rural primary care practices across the U.S. The questionnaire will assess EHR and HIT implementation at the facility level; their relative need for different components of the HIT workforce; and whether they train and develop HIT staff from within, hire new staff, employ consultants, and/or join forces with other institutions to fill these workforce needs. We will include questions about the institutions’ current HIT workforce, expected future demand, education and training resources available to the institution and its staff, and other workforce-related factors that support or impede the practices’ implementation and use of HIT. Our descriptive analyses will produce national rural and sub-rural estimates of findings. The study will also identify relationships between specific practice attributes and HIT workforce variables. Funded by HRSA’s Office of Rural Health Policy.

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Rural FLEX Program In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of...
National Rural Hospital Flexibility Program Tracking Project

In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.

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Rural Family Practice Residency Programs Chartbook This chartbook makes previously unreported information from our national survey of 453 FP residency...
Chartbook of Family Practice Graduate Medical Education Programs in Rural America

This chartbook makes previously unreported information from our national survey of 453 FP residency directors available to medical educators and policy makers. As part of this survey, programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas (RUCAs), the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. The chartbook presents national, regional, state, and division findings, presented by type of geography (i.e., isolated small rural, small rural, large rural, and urban), type of rural training experience (i.e., model family practice clinic, block rotations, rural training tracks, and continuity clinics), and other residency characteristics. Funded by HRSA’s ORHP.

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Rural Family Planning Services Considerable controversy exists about the types of family planning services that should be...
Accessibility of Family Planning Services to Rural Residents

Considerable controversy exists about the types of family planning services that should be available in rural areas. This study constructed an inventory of family planning services available in rural Idaho, determined the factors associated with observed variations in the range of available services, and examined the policy implications of the findings. A questionnaire was sent to physicians who were the potential providers of such services to determine service volumes and access issues.

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Rural Family Medicine Residency Training Master File Little is known about how well various types of rural-focused family medicine residency training...
A Novel Master File of Rural Family Medicine Residency Training: Program Models and Graduate Outcomes

Little is known about how well various types of rural-focused family medicine residency training programs, particularly osteopathic residencies, produce physicians for rural practice. This study examined program content and training locations as well as rural and urban practice outcomes for graduates of rural-centric family medicine residency training programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Rural Family Medicine Residency Survey Follow-Up This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in...
Rural Family Medicine Residency Training Follow-Up Survey Regarding Amount and Types of Rural Training Experiences

This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in rural areas of the United States. In 2000 we conducted a national survey of all family medicine residency training programs in the nation to identify the type and extent of residency training that actually took place in rural locations. This study administered a follow-up mail survey to all family medicine residency training programs (about 440) using an instrument that was modified slightly to add a few key questions. This allowed us to examine changes since 2000 in the number of programs located in rural places, the nature of these programs, funding sources and staff configurations, as well as the amount of time that training takes place in federally funded health centers and other types of facilities.

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Rural EMS Workforce Rural populations frequently reside great distances from hospital emergency departments or urgent...
The Pre-hospital Emergency Medical Services Workforce in Rural and Urban Areas

Rural populations frequently reside great distances from hospital emergency departments or urgent care facilities, underscoring the need for timely and effective pre-hospital emergency medical services (EMS). Numerous reports and anecdotal evidence indicate that rural EMS agencies face significant resource challenges in terms of sustainable funding, staff recruitment and retention, and staff skill maintenance. Reliable data to quantify the extent of these problems have been lacking. This project aims to quantify systematically workforce supply and demand disparities between rural and urban EMS systems in a sample of states distributed across the U.S. Study results will inform policy options to ensure an adequate supply of EMS personnel in rural areas. This study will analyze secondary data collected via a 2008 telephone survey of all ground-based pre-hospital EMS providers in nine states. Analyses of EMS agency service area coverage, patient volume, funding basis, organizational type, staffing, vacancies, and medical direction will yield statistical comparisons between urban and three subcategories of rural areas. Findings on rural-urban EMS resource distribution will also be displayed in maps for each state. Funded by HRSA’s Office of Rural Health Policy.

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Rural Emergency Medical Services This study retrieved data on every vehicular injury accident occurring in Okanogan County,...
Regionalization of Rural Emergency Medical Services (EMS)

This study retrieved data on every vehicular injury accident occurring in Okanogan County, Washington, in 1990. Information was collected on location of accident, type and severity of injury, initial pre-hospital response, initial transportation, involvement of local health care system, transfer to facility outside county, patient outcomes, and demographics. The study included (1) a description of the type and nature of crashes and injuries and the involvement of local and distant components of the EMS, (2) an examination of the extent to which the existing rural EMS is regionalized, and (3) policy-oriented recommendations.

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Rural Definitions We published an article entitled "Rural Definitions for Health Policy and Research" in the American...
Description of Differences Between Seclected Rural-Urban Taxonomies

We published an article entitled “Rural Definitions for Health Policy and Research” in the American Journal of Public Health in which we describe and compare various rural and urban taxonomies that were in use, describing their characteristics, strengths, and weaknesses depending on the purpose at hand.

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Rural Definition Reclassification This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area...
Rural Definition Reclassification Project

This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area (RUCA) codes.

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Rural Capacity for Family Physicians This paper addresses the ability of smaller and underserved rural communities to financially...
How Many Physicians Can a Rural Town Support?

This paper addresses the ability of smaller and underserved rural communities to financially support needed physicians. We used Washington State data to test the feasibility of constructing physician income potential models. The total spending for primary care physicians was estimated using age-sex-poverty status coefficients from the National Medical Expenditure Survey, supplemented by unique Part B Medicare data on the proportion of rural physician revenue from non-office based services. Community size and the distance to other cities and towns were crucial determinants of market share and thus the capacity of small towns to attract and support primary care practices. The distribution of physicians among towns followed predicted economic potential. That potential varied dramatically even among towns with similar populations due to the pull of competing locations for primary care. Surprisingly, the types of rural communities most likely to have fewer physicians than suggested by the projected potential were not small isolated towns, but larger communities with above-average population growth, closer proximity to metropolitan areas and somewhat lower average family incomes. Strategies such as the National Health Service Corps use a one-time “signing bonus” to overcome physicians’ initial reluctance to locate in an underserved area. An alternative approach is to address long-term income disadvantages by offering continuous subsidies such as the enhanced Medicare payments for certified Rural Health Clinics or the 10% Medicare supplemental payments for care provided in a HPSA. Funded by HRSA’s ORHP.

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Rural C- Sections This project provided information on how physician training, community specialty mix and other...
Rural C-Sections and Family Physicians

This project provided information on how physician training, community specialty mix and other factors are related to the provision of c-sections in rural communities. We examined the percentage of the c-sections performed on rural service area residents that were done in small rural hospitals, whether family physicians did most of these procedures in rural hospitals where there are no obstetricians, their competence in performing c-sections, and factors associated with their performance of this procedure. Data were obtained through Computerized Hospital Discharge Database (CHARS) inpatient hospital abstracts supplemented by a telephone survey of all Washington State rural hospitals and a mail survey of rural physicians. Funded by HRSA’s ORHP.

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RUCA Development & Description The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and...
RUCA Development Project: Demographic Description and Frontier Enhancement

The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and with support from, HRSA’s ORHP and the Department of Agriculture. The RUCAs are a census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area (UA) and Urban Place (UP) definitions with commuting information to characterize the nation’s Census tracts regarding their rural and urban status and relationships. The codes are based on whether a Census tract is located in a UA or UP and on the destination of its largest and second largest commuting flows. This project (1) produced and described the base 1998 demography of the RUCA code areas, (2) created quality state maps of the RUCA codes, and (3) has made this information and the codes easily available on the Web. The demographic description of the RUCA codes involved standard cross-tabulation analysis of the code areas nationally, regionally, and by state. Technical notes and maps are posted at www.depts.washington.edu/uwruca”>UW RUCA.

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RTT Technical Assistance Program This project is building a national partnership between professional groups, academic units,...
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education

This project is building a national partnership between professional groups, academic units, governmental entities, and sustaining organizations to provide ongoing support and technical assistance to community-embedded rural health professions education. The project is (1) establishing a network of organizations and experts by visiting Rural Training Tracks (RTTs), creating RTT-state office of rural health coalitions, and convening stakeholder meetings; (2) building a Web portal with a virtual library of tools, information, and access to technical assistance; (3) developing new models and programs while sharing best practices; (4) initiating a process for identifying and training new leaders; and (5) publishing a final report. Under the NRHA umbrella and anchored by project directors and field offices in Idaho, Ohio, and Washington DC, the program is connecting RTT program directors, faculty, and staff with state offices of rural health, a rural assistance center, and a rural research center to bolster existing RTTs, foster new programs, and utilize community expertise in identifying systemic issues and remedies. While focused on rural medical education, the network will provide a model for community-embedded training and an infrastructure for training other rural health professions. UW WWAMI RHRC researchers are designing and maintaining a research data set and protocol for RTT site visits, including consents and IRB approval. The RHRC is the repository of these data-gathering efforts and will analyze and synthesize data underpinning reports and other dissemination activities. The RHRC is sharing data and coordinating its effort with the Graham Center in Washington DC to promote policy development, and assisting in the preparation of a final evaluation and report of this demonstration program.

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Family Physicians Choosing Rural Practice This project will survey physicians trained in rural-centric family medicine residencies to...
Family Medicine Rural Training Track Graduates: Determinants of Rural and Urban Practice

This project will survey physicians trained in rural-centric family medicine residencies to understand the characteristics, experiences, and attitudes that influenced their rural or urban practice choices. Understanding the factors that determine practice choices of RTT graduates can help improve recruitment of residents who will ultimately fulfill RTTs’ mission of preparing family physicians for rural practice.

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Retention of NHSC Recipients This study examined the retention and distribution of the 6,300 NHSC allopathic physician...
National Health Service Corps Scholarship Recipient Retention Study

This study examined the retention and distribution of the 6,300 NHSC allopathic physician scholarship recipients graduating from medical schools for the years 1975 through 1983. The roster of these scholarship recipients was linked with American Medical Association data to provide information on their location, specialty, and practice status. Recipients were examined in terms of their propensity to remain in their original ZIP code, county, state, and rural/urban status location. In addition, their locational patterns were compared to other graduates. Recipients’ specialty, type of practice, and NHSC length of obligation were also evaluated.

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Recruitment of Rural Women Physicians This study examined differences in the factors female and male generalist physicians considered...
Best Strategies for Recruiting Women Physicians to Rural Practice

This study examined differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identified the practice arrangements that successfully recruited female generalist physicians to rural areas. We mailed questionnaires to generalist physicians recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Compared to men, recruited women were younger, less likely to be married, had fewer children, and worked fewer hours. Women were more likely than men to have been influenced by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of child care, as well as the interpersonal aspects of recruitment. Commonly reported themes reflected the desire for flexibility regarding family issues and the value placed on honesty during recruitment. Men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. The most common methods for obtaining information about practice opportunities were personal networking, prior training experience, recruiters, and outreach by medical practices. This study concluded that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues if they want to achieve a gender-balanced physician workforce. Funded by HRSA’s ORHP.

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Radiation Therapy in Rural U.S. This study used cancer registry data from 10 U.S. states to examine which rural cancer patients...
Use of Recommended Radiation Therapy in the Rural U.S.

This study used cancer registry data from 10 U.S. states to examine which rural cancer patients received recommended radiation therapy and what factors influenced receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service location and cancer support program development. Funded by HRSA’s ORHP.

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Quality of Rural Perinatal Care The equitable provision of high-quality obstetric care is a major priority of our health care...
The Process and Quality of Rural Perinatal Care: A National Study

The equitable provision of high-quality obstetric care is a major priority of our health care system, and nowhere is access to such care more threatened than in rural areas. This project determined whether rural mothers receive less care and experience worse outcomes than their urban counterparts, whether racial and ethnic minorities living in rural areas experience different outcomes than their counterparts, and what other factors are associated with less care and poorer outcomes. Data were compiled from the National Center for Health Statistics’ Linked Birth/Death set and the Bureau of Health Professions’ Area Resource File. Measures of process of care included late or no prenatal care, lack of care in the first trimester, and inadequate care as measured by the Kotelchuck Index. Outcome measures included infant mortality and the percentage of children born at low and very low birthweight. This study also compared birth outcomes and process of care for minorities across rural areas and with their urban counterparts. Funded by HRSA’s ORHP.

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Prostate Cancer Treatment in Rural This research will use cancer registry data from 10 states to examine the degree to which rural...
Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?

This research will use cancer registry data from 10 states to examine the degree to which rural residents diagnosed with early-stage prostate cancer access the full range of surveillance, surgical, and radiation treatment options. Study findings will inform cancer centers, advocacy groups, rural program planners, and policymakers about services and programs needed to ensure that rural prostate cancer patients can choose from among all treatment options.

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Programs Producing Rural Physicians This national study used longitudinal data on medical school specialty and practice location choice...
Which Training Programs Produce Rural Physicians? A National Health Workforce Study

This national study used longitudinal data on medical school specialty and practice location choice to determine the extent to which the nation’s medical schools and residency programs varied in their production of rural physicians. This facilitated the identification of medical school and residency program characteristics associated with the highest yield of rural physicians. Funded by HRSA’s ORHP.

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Programs Producing Rural PAs Physician assistants (PAs) are an important part of the rural health workforce, and their roles are...
Which Physician Assistant Training Programs Produce Rural Physician Assistants? A National Study

Physician assistants (PAs) are an important part of the rural health workforce, and their roles are expected to grow. While PAs are more evenly distributed across the rural-urban continuum than physicians, long-term trends of medical specialization, increasing cost of training, and demographic change in the PA workforce have contributed toward decreasing PA participation in rural and primary care. This study will identify the PA training programs that are most successful at producing graduates who practice in rural areas, focusing particularly on PAs who graduated from training in the past ten years. Funded by HRSA’s Office of Rural Health Policy.

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Problem Drinking Among Rural Veterans This study will use national data to measure recent trends in problem drinking among VA-eligible...
Problem Drinking: Trends Among Rural Veterans–A National Study

This study will use national data to measure recent trends in problem drinking among VA-eligible adults in rural and urban locations and couple these data with the locations of VA services and substance abuse treatment facilities to identify rural locations where alcohol treatment services are limited. This project is funded by the Veterans Administration Office of Rural Health, through a contract with the northwest Portland, Oregon, Veterans Affairs Medical Center.

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Primary Care Trends This project critically reviewed the recent waning of primary care and its implications for rural...
Primary Care at a Crossroads Project

This project critically reviewed the recent waning of primary care and its implications for rural populations. The paper chronicled historical changes and trends, put these changes in the larger health care system context, and concluded with a set of policy recommendations that detail options available to policy makers and leaders of the nation’s medical educational establishment.

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Practice Locations of Women Physicians While women are becoming an increasingly large percentage of the graduates of medical schools and...
The Rural/Urban Practice Location Patterns of Women Medical School Graduates

While women are becoming an increasingly large percentage of the graduates of medical schools and of the generalist specialties in particular, they are much less likely to locate their practices in rural towns. If this trend were to persist, implications for access to care in rural areas would be substantial. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future. The study first examined national physician location patterns by medical school graduation cohort per gender differences. The second phase dealt with the production of female generalist physicians by medical schools. Funded by HRSA’s ORHP.

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Policy Activities of AMCC The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives...
Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)

The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives of state government responsible for the delivery of health care to women and children. The major objective of AMCC is to improve access to obstetrical care for socially vulnerable women. The committee successfully served as a forum in which to resolve administrative problems arising between private obstetrical providers and the state’s Medicaid program and was influential in persuading the state legislature to increase Medicaid eligibility, raise provider reimbursements, and improve social services to pregnant women.

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Physician Residency Rural Training The supply of rural physicians is in part determined by the number of family physicians who receive...
Physician Residency Rural Training Baseline Study

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA’s ORHP.

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Physician Access for Rural Elderly Patients in rural areas may utilize less medical care than urban patients because of differences...
Access to Physician Care for the Rural Medicare Elderly

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA’s ORHP.

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Perinatal Technology in Rural Washington One of the major issues confronting rural health care providers is the problem of acquiring complex...
Diffusion of New Perinatal Technology into Rural Areas of Washington State

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

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Oral Health in Rural This study determined whether shortages of dentists in rural areas of the United States are...
Dentist Supply, Access to Dental Care, and Oral Health Among Rural and Urban Residents: A National Study

This study determined whether shortages of dentists in rural areas of the United States are associated with impaired access to dental care and a higher prevalence of dental disease. Using detailed dentist supply data from the American Dental Association Dentist Masterfile and recent survey data from the nationally-representative Behavioral Risk Factor Surveillance System, we characterized dentist supply-oral health relationships by overall rural vs. urban location and a four-level, rural-urban grouping for the nation and individual states.

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Obstetrical Access in Washington A survey of all potential providers of obstetrical care in Washington State was conducted in 1989,...
Obstetrical Access in Washington State

A survey of all potential providers of obstetrical care in Washington State was conducted in 1989, and results were compared to an earlier survey to assess the extent to which obstetrical access had changed. Although the massive exodus of family physicians from obstetrical practice appeared to have slowed during the follow-up period, there was still substantial net attrition among this group of providers. By contrast, the supply of obstetricians and midwives seemed to be stable. Despite the greater obstetrical participation rate of rural practitioners, members of this group were also quitting obstetrics faster than they could be replaced.

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NP Distribution using Available Data This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural...
Assessing rural-urban nurse practitioner supply and distribution in 12 states using available data sources

This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural vs. urban) derived from two sources: state license records and National Provider Identifier (NPI) data. Estimates of state NP supply from license data were found to be higher than NPI-derived estimates for most, but not all states. While data from both license and NPI sources can be useful for health workforce planning, the limitations of each source should be acknowledged and workforce comparisons should be limited to estimates derived from the same types of data.

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NHSC Evaluation A major impediment to access to care is the shortage of primary care physicians in rural locations...
National Health Service Corps Evaluation

A major impediment to access to care is the shortage of primary care physicians in rural locations and inner cities. This extension of an earlier study evaluated the National Health Service Corps (NHSC) scholarship program through a mail survey with phone encouragement of NHSC scholarship recipients who graduated from medical school during 1975-83. The study examined their retention experience, locational career patterns, demographic and practice characteristics, and service in rural sites. Funded by HRSA’s ORHP.

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National PA Study, 1996 The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national...
National Study of Physician Assistants

The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national survey of a random sample of physician assistants (PAs). The RHRC completed a follow-up survey of all the graduates of the University of Washington’s MEDEX Northwest PA program. The follow-up study, in which North Dakota Center for Rural Health Services staff took the lead, examined differences in rural and urban PA content of practice, satisfaction, practice type, practice characteristics, and demographic characteristics. Geographical and chronological career patterns of the PAs were investigated, as well as issues related to prescriptive authority and professional autonomy.

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Medicare Bonus Payments in HPSAs Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat...
Medicare Bonus Payments for Physician Care in HPSAs

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in areas where there is a federally designated shortage of generalist physicians. This study examined the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program using a retrospective cohort design utilizing 1998 Medicare Part B data. Physician specialty was determined through American Medical Association Masterfile data. Rural status was determined by linking this ZIP code to its Rural-Urban Commuting Area Code (RUCA). There were 39,780 providers in the study cohort: 24.9% generalists, 53.5% medical and surgical specialists, and 21.6% nonphysician providers. Over $4 million in bonus payments were made to providers in the Health Professional Service Area (HPSA) sites, with a median overall payment of $173. Specialists and urban providers received 58% and 14% of the bonus reimbursements respectively. Nearly a third of the potential bonus payments ($2 million) were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites. Many providers who should have claimed the bonus did not, and many who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers as well as a system that prospectively determines provider eligibility. Funded by HRSA’s ORHP.

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Medical Education and Rural Practice Review This literature review critically examined the research literature related to physician...
Review of the Literature on Medical Education Programs Promoting Rural Practice Location

This literature review critically examined the research literature related to physician undergraduate and graduate medical education and rural practice location. While topics related to rural location choices such as federal and state programs and recruitment and retention were touched upon, the emphasis of the review was on the educational programs themselves. The main objective of the review was to determine what we currently know and what gaps in the literature need to be addressed in order to develop sound public policy. Funded by HRSA’s ORHP.

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MEDEX PA Study, 1994 This project, performed in partnership with MEDEX Northwest in the School of Public Health,...
MEDEX Northwest Physician Assistant Study

This project, performed in partnership with MEDEX Northwest in the School of Public Health, examined the locational choices and role of physician assistants (PAs) in the WAMI states, explored the use of PAs as physician extenders, and described the evolution of PA training and function over the past two decades. We surveyed all MEDEX graduates to identify factors that predict selection of and retention in rural locations. Results of this study improved the ability of training programs to select trainees likely to pursue successful careers in underserved rural areas and identified the kinds of professional environments conducive to attracting and retaining mid-level health care providers.

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MD Views of Rural Hospital Closures This project surveyed the physicians of rural towns whose sole small general hospitals closed...
Physician Perceptions of the Closing of their Small Rural Hospitals

This project surveyed the physicians of rural towns whose sole small general hospitals closed between 1980 and 1988. All locatable physicians who were practicing in the hospital closure towns at the time of the closures were surveyed with a questionnaire similar to that employed in a parallel survey of hospital closure town mayors. The study concentrated on physician perceptions of the reasons the hospitals closed, the consequences of the hospital closures, and the role the physician played in the closure process. Government reimbursement policies and poor hospital management were cited as principal reasons for hospital closures.

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Mayor Views of Rural Hospital Closures This project involved a survey of 130 mayors of rural towns whose sole small general hospitals...
Mayor Perceptions of the Closing of their Small Rural Hospitals

This project involved a survey of 130 mayors of rural towns whose sole small general hospitals closed between 1980 and 1988. Mayors attributed the closure of their hospitals primarily to government reimbursement policies, poor hospital management, and lack of physicians. They reported that they had little warning that their hospitals were in imminent danger of closing. Well over three-fourths of the mayors felt that access to medical care and health status had deteriorated in their community after hospital closure, and over 90% indicated that the hospital closure had substantially impaired the community’s economy.

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Low-Risk Obstetric Care This study, which was predominantly funded by AHCPR but was also supported through the HRSA's ORHP,...
Low-Risk Obstetric Care Resource Use

This study, which was predominantly funded by AHCPR but was also supported through the HRSA’s ORHP, was part of a large multifaceted project that examined low-risk obstetric care in Washington State through surveying obstetric providers and abstracting detailed information about their patients. This study used the provider as the unit of analysis. Differences in resource use (e.g., visits, tests, and procedures) between rural and urban obstetricians and between rural and urban family physicians were examined in detail.

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Location of PA Practices Despite the need for generalist care providers in rural areas experiencing shortages of generalist...
Physician Assistant Location and Geographic Trajectories: A National Study

Despite the need for generalist care providers in rural areas experiencing shortages of generalist physicians, the percentage of physician assistants (PAs) that practice in small towns has been decreasing. This study examined PA rural and urban location behavior and their geographic trajectories over time based on national PA data collected in an earlier study. Data from sources such as the Area Resource File were used to characterize the areas where PAs were located. Factors such as PA demography, educational program type and location, preceptorship location, and previous health care provider status were examined. As the American health care delivery system changes, with workforce policies that focus more sharply on generalist care, the need to better understand PA practices is crucial. Funded by HRSA’s ORHP.

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International Medical Graduates: States' Use of Conrad 30 J-1 Visa Waivers States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban...
The Influence of State Policies and Practices on J-1 Visa Waiver Physicians' Service in Rural Areas

States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study, funded by HRSA’s Federal Office of Rural Health Policy, collected quantitative and qualitative information from states to assess how state policies and practices shape IMG recruitment and practice in underserved areas through Conrad 30 J-1 visa waiver programs. The first  report provides quantitative data on trends in waiver usage. The second report describes findings from interviews with Conrad 30 program personnel in 32 states and includes information on J-1 waiver physician retention for states with available data.

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Impact of Malpractice We studied all family physicians (470) who purchased obstetrical malpractice insurance from the...
Impact of Malpractice Claims

We studied all family physicians (470) who purchased obstetrical malpractice insurance from the largest malpractice insurer in Washington State (WSPIEA) from 1982 to 1988. One-third discontinued obstetrics but remained in practice, and these physicians were older, more likely to practice in an urban area, and more likely to be in solo practice. Rural family physicians were less likely to quit practicing obstetrics than their urban colleagues. Obstetrically related malpractice claims against family physicians were relatively infrequent and are not a factor in the decision of most family physicians who stop practicing obstetrics.

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IMG On-Line Atlas The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic...
On-Line Atlas of International Medical Graduates

The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic distribution of IMGs over the past 20 years through a series of maps. The maps are intended to provide useful information regarding changes in the global production of IMGs and the distribution of IMGs in the United States over time.

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HPSAs and Rural Health Care Access This study examined the degree to which persistence of primary care health professional services...
Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America

This study examined the degree to which persistence of primary care health professional services area (HPSA) designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services. It used a five-level classification of rural counties measuring partial- vs. whole-county persistence of primary care HPSA designation that stratified rural populations by socioeconomic status (SES), race/ethnicity, primary care supply, health insurance uptake, and access to needed health care services. The study found that those U.S. rural counties that were persistently designated as whole-county HPSAs had much lower SES, and adults residing in these counties reported substantial financial obstacles to obtaining needed health care services. Rural counties that were persistently designated as whole-county HPSAs also faced severe provider shortages, and adults residing in these locations were less likely to have a regular primary care provider. This study was funded by HRSA’s Office of Rural Health Policy.

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Hospital Closures and MD Supply This study determined whether the supply of physicians decreased subsequent to a rural hospital...
Impact of Hospital Closures on Physician Supply

This study determined whether the supply of physicians decreased subsequent to a rural hospital closure during a nine-year period ending in 1988. The study (1) examined changes in physician manpower before, after, and at the time of the closure and (2) examined the association of town size, hospital size, and distance to other hospitals with hospital closure. The hospital closure towns most likely to lose physicians had few physicians before closure, were relatively remote from both urban areas and other hospitals, were located in sparsely populated counties, and tended to have for-profit ownership.

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HIT Workforce Development in Rural Community Colleges Successful implementation of health information technology (HIT) in rural areas depends on the...
HIT Workforce Development in Rural-Serving Community Colleges

Successful implementation of health information technology (HIT) in rural areas depends on the availability of a well-trained HIT workforce, and community colleges are key educational resources for producing this workforce. This study examined HIT workforce development programs in community colleges in order to increase understanding of the types of programs offered, describe the characteristics and sources of community college HIT curricula, highlight how these programs may be reaching underserved populations and students with limitations to accessing classroom-based courses, and identify barriers faced by these programs in achieving their HIT education goals. Information about the strengths and needs of the nation’s community college HIT education programs should help inform future HIT skills training programs and contribute to growing and strengthening the HIT workforce.

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Health Professions Education in Washington This study used the U.S. Department of Education's Integrated Postsecondary Education Data System...
Health Professions Education in Washington State: 1996-2004 Program Completion Statistics

This study used the U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) database to determine the number, sex and race/ethnicity of persons completing postsecondary health career education programs throughout Washington State. The report shows changes over time for 36 selected programs, ranging from physician, nursing, allied health, dental health, pharmacy and other health care education programs. The 2004 study was funded by the Washington State Workforce Training and Education Board. The 2002 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Health Center Expansion and Recruitment in WWAMI States Federally qualified health centers (HCs) face major barriers in recruiting and retaining health...
Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)

Federally qualified health centers (HCs) face major barriers in recruiting and retaining health professionals, yet there have been no projections of key health professions staffing needs for HCs and proposed new HCs. A study by the University of Washington Rural Health Research Center (RHRC) and collaborators described the current staffing needs of HCs across the United States and the staffing, recruitment, and retention issues that HC chief executive officers (CEO) regard as most critical throughout the nation as a whole. Presented here is a subset of the findings from the larger national study for HCs located in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) overall and by urban and rural geography.

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Health Center Expansion and Recruitment Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals,...
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project

Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals, yet there were no projections of key health professions staffing needs for HCs and proposed new HCs. This collaborative study with the South Carolina RHRC described the staffing needs of rural HCs and ascertained the staffing, recruitment, and retention issues that HC CEOs regarded as most critical. The National Association of Community Health Centers administered a mail questionnaire to the CEOs of all CHCs in the nation (about 845) that profiled their current staff vacancies, projected staffing needs, recruitment and retention issues, center site expansion plans, and CEO perception of policies that would facilitate recruitment and retention. This joint center project was a collaborative one between HRSA’s FORHP, BPHC, and BHPr.

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Health Care Reform in Rural Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues...
Health Care Reform Policy Briefs on Rural Health Workforce Issues

Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues related to health care reform. The published products of these analyses have been posted to the WWAMI RHRC Web site.

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Health Care for the Rural Uninsured This study described the contributions of family and general practice physicians from Wyoming to...
Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?

This study described the contributions of family and general practice physicians from Wyoming to the health care safety net. We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women were less likely than men to make this mean income, even when controlling for hours worked. Close to two-thirds claimed bad debt of over $10,000, and 29.3% noted forgiven debt of over $10,000. Physicians with less income than the prior year were more likely to decrease their charity care. Wyoming family physicians provide significant amounts of informal safety net care, which is threatened by income loss. Funded by HRSA’s ORHP.

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Future Supply of Family Medicine Physicians This study investigated the implications of declining medical school interest in primary care...
The Future of Family Medicine and Implications for Primary Care Physician Supply

This study investigated the implications of declining medical school interest in primary care careers as it impacts rural and underserved areas. The study examined data from the American Association of Medical Colleges, the 2005 American Medical Association Masterfile, and the American Osteopathic Association Masterfile, as well as survey data from residency directors and students to describe recent trends in medical school interest and national match rates for family medicine and primary care. Funded by HRSA’s FORHP.

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Federal Funding and MD Production This study described the graduates of all American medical schools from 1976 to 1980 and from 1981...
Relationship Between Federal Funding and Medical School Output

This study described the graduates of all American medical schools from 1976 to 1980 and from 1981 to 1985 in terms of their specialty and geographic location and correlated these variables with the amount of Title VII funds received by specific schools during those periods. Two hypotheses that were tested were (1) Title VII has had a positive impact on increasing the proportion of graduates choosing primary care specialties and practicing in rural and underserved areas, and (2) graduates of community-based schools are more likely to choose careers in primary care and to practice in rural and underserved areas than are graduates of traditional medical schools. Data for each medical school were aggregated by school and linked with data on Title VII and other federal funding from 1976 to 1985.

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Family Medicine Residency Network Study This survey project contrasted the role, practice type, and characteristics of graduates from the...
Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs

This survey project contrasted the role, practice type, and characteristics of graduates from the residency network associated with the University of Washington Department of Family Medicine who were located in rural versus urban communities. The geographic trajectories by graduate cohort and program were analyzed. In addition, the extent to which the program has been successful in placing and retaining graduates within rural communities and the region was evaluated.

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Family MD Views of Assisted Suicide With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain...
Family Physician Attitudes Toward Physician-Assisted Suicide

With recent laws allowing physicians to assist in a terminally ill patient’s suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified. This study used data from a 1997 survey of family physicians (FPs) and general practitioners (GPs) in Washington State to determine factors associated with attitudes toward physician-assisted suicide. A questionnaire was mailed to all active FPs/GPs in Washington State. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. One-fourth of the respondents overall indicated support for physician-assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% did not know. Over half would not include physician-assisted suicide in their practices, even if it were legal. Attitudes about physician-assisted suicide varied significantly between urban females and rural males, with the former being more supportive of assisted suicide than the latter. Many respondents, especially females, were uncertain of their positions concerning the legalization of and their willingness to assist suicides. Substantial differences in opinion toward physician-assisted suicide existed between physicians based on gender and rural-urban practice location. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents.

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Family MD Practice Locations In this study, responses to a survey of graduates from the residency network associated with the...
Geographic Career Trajectories of Family Practice Physicians

In this study, responses to a survey of graduates from the residency network associated with the University of Washington Department of Family Medicine were analyzed related to their rural and urban career trajectories. This study examined the locational patterns of the graduates in terms of initial site location, practice moves, lengths of stay, prior movement experience, gender, and graduation cohort.

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Emergency Care of Rural Elderly This study used Medicare data to compare emergency department (ED) use by rural and urban elderly...
The Emergency Care of the Rural Elderly

This study used Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The Health Care Financing Administration’s National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. This study found that the rural elderly living in remote areas were 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly did not vary meaningfully by location. Most ED visits by this group were for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, local EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Funded by HRSA’s ORHP.

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Educational Strategies to Encourage Rural NP Practice Persistent shortages of primary care physicians in rural areas have increased the need to educate...
What Strategies Are Nurse Practitioner Educational Programs Using to Encourage Rural Practice?

Persistent shortages of primary care physicians in rural areas have increased the need to educate nurse practitioners (NPs) for rural careers. Medical schools have identified factors associated with rural practice by physicians and used this knowledge to develop rural training programs, but less is known about factors associated with rural NP training and practice or the extent to which NP programs deploy such strategies. This study will quantify and describe NP education programs that encourage NPs to practice in rural areas and identify data sources that could be used in future studies of the effectiveness of these programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Economic Impact of HRSA Rural Network & Outreach Grants This study analyzed the economic impact created by HRSA Network Development and Outreach grantees....
Economic Impact Analysis of HRSA’s Rural Health Care Services Outreach and Rural Health Network Development Grant Programs

This study analyzed the economic impact created by HRSA Network Development and Outreach grantees. The analyses were conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focused on a cohort of grantees, the study used methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC had a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

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Economic Impact of HRSA Rural Network & Outreach Grants This study analyzed the economic impact created by HRSA Network Development and Outreach grantees....
Economic Impact Analysis of HRSA's Rural Health Care Services Outreach and Rural Health Network Development Grant Programs

This study analyzed the economic impact created by HRSA Network Development and Outreach grantees. The analyses were conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focused on a cohort of grantees, the study used methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC had a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

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Deregionalization of Rural Perinatal Care The regionalization of rural perinatal care during the 1980s significantly lowered neonatal...
Are Rural Perinatal Care Systems Deregionalizing?

The regionalization of rural perinatal care during the 1980s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study determined whether there was evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization had adversely affected neonatal mortality among infants born to rural residents. We analyzed national Linked Birth Death Data Set data over a 10-year period. The study population included all low-birthweight infants born to rural residents. This study demonstrated the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA’s FORHP.

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Contributions of Physicians, APNs, and PAs to Rural Primary Care This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs),...
The Current Contribution of Physicians, Advanced Practice Nurses, and Physician Assistants to the Rural Primary Care Workforce

This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs), and physician assistants (PAs) regarding their primary care visit productivity and scope of practice. Through surveys, this study examined the contributions of physicians, APNs, and PAs by state, degree of practice rurality, practice characteristics, and primary care HPSA status in order to provide information on a range of rural primary care workforce needs in the coming decades. Funded by HRSA’s Office of Rural Health Policy.

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Community Paramedicine Research Consensus Conference Background: Community paramedicine is a new model of providing access to basic health care...
National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda

Background: Community paramedicine is a new model of providing access to basic health care services. Community paramedicine extends paramedics’ traditional emergency response roles through additional education that enables them to see patients in their home or community setting and perform procedures already in their skill set. Community paramedics provide care under the supervision of an ordering physician or advance practice provider. Community paramedics are providing these kinds of services for otherwise underserved communities in demonstration sites in the U.S. and Canada. While there are reports of successful implementation of this novel approach to expanding primary care access, there is a paucity of objective, systematic research on the outcomes of these programs. This project identified appropriate research questions and appropriate data to increase understanding of the outcomes of community paramedicine. Goal: This project developed a national research agenda for the emerging field of community paramedicine based on facilitated discussions at a National Consensus Conference on Community Paramedicine. Collaboration: The study was conducted collaboratively by researchers at the University of Washington (UW) WWAMI Rural Health Research Center (RHRC) and the North Central Emergency Medical Services Institute. Funding was from a conference grant by the Agency for Healthcare Research and Quality. The UW’s WWAMI RHRC researchers completed a summary of topics and key points discussed during the National Consensus Conference on Community Paramedicine (October 1-2, 2012) and a community paramedicine research agenda report.

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Chronic Illness among Rural Residents This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine...
The Burden of Chronic Illness Among Rural Residents: A National Study

This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine trends–by type of geographic area, race/ethnicity, and risk factors–in hypertension, diabetes, hypercholesterolemia, and asthma, as well as patterns of screening for two of these conditions. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Characteristics of National Rural Nurse Workforce This national study characterized changes in the demographic, education, and practice...
Long-Term Trends in Characteristics of the Rural Nurse Workforce: A National Health Workforce Study

This national study characterized changes in the demographic, education, and practice characteristics of registered nurses (RNs) in rural and urban areas from 1980 to 2004. Study data came from the National Sample Survey of Registered Nurses (NSSRN) collected between 1980 and 2004. RNs were categorized into urban, large rural, small rural, and isolated small rural by residence and work location using the Rural-Urban Commuting Area taxonomy. The study examined changes since 1980 in rural RN number, percent employed in nursing, age, gender, race/ethnicity, age at first RN degree, types of degrees attained, type of work, salaries, the types of areas where the RNs work, and their likely commuting patterns. By examining trends in rural RNs characteristics over the past two decades, this study provided important information for projecting future trends in RN supply for rural communities.

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Changes in MD Supply National rural health policy development depends on an accurate and up-to-date assessment of...
National Changes in Physician Supply

National rural health policy development depends on an accurate and up-to-date assessment of physician supply. This project described the supply of generalist physicians and osteopaths in rural areas of the United States. We used data from the AMA and Area Resource File to determine the total supply of practicing physicians in metropolitan and nonmetropolitan counties in 2005. We used Urban Influence Codes to classify nonmetropolitan counties based on their adjacency to a metropolitan county and the size of the largest urban place within the county. We assessed the supply of physicians in the smallest and most isolated areas of the country and analyzed rural physician supply on a state-by-state and regional basis. Funded by HRSA’s FORHP.

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Care for Lung Disease among Rural/Urban Medicare Beneficiaries This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural...
National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?

This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural and urban patients hospitalized with chronic obstructive lung disease to prescribed home oxygen and the needed equipment. Funded by HRSA’s FORHP.

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Care for Acute Myocardial Infarction in Rural Hospitals: 1994-1995 Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most...
Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995

Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most recommended interventions require no sophisticated technology and should be available in rural and urban hospitals. This study examined the quality of AMI care in rural hospitals. It was a cohort study using data from the 1994 and 1995 Centers for Medicare & Medicaid Services’ Cooperative Cardiovascular Project and the 1995 American Hospital Association’s Annual Survey of Hospitals. The study included U.S. acute-care hospitals caring for patients with AMI, and Medicare beneficiaries ages 65 and older directly admitted to four types of acute-care hospitals–remote small rural, small rural, large rural, and urban–for a confirmed AMI between 1994 and 1995. Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive recommended AMI treatments. Medicare patients treated in rural hospitals were less likely than urban hospitals’ patients to receive aspirin during hospitalization or at discharge, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only one treatment–ACE inhibitors at discharge–was used more for patients in rural hospitals. Medicare patients in rural hospitals had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals. Efforts are needed to help hospital medical staffs, especially those in rural areas, develop systems to ensure that patients receive recommended AMI treatments. Funded by HRSA’s ORHP.

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Cancer Screening in Rural America This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to...
Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?

This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to explore the prevalence and trends in screening for four types of cancer (breast, colorectal, cervical, and prostate) among survey respondents from urban and various types of rural areas and among white compared to minority populations. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Cancer Care for Rural Colorectal Cancer Patients This study compiled a comprehensive database linking Surveillance Epidemiology and End Results...
Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study

This study compiled a comprehensive database linking Surveillance Epidemiology and End Results (SEER) cancer registry, Medicare claims, American Medical Association Masterfile, and other data to examine access to cancer services in a sample of rural, Medicare-insured colorectal cancer patients of different racial and ethnic groups. Funded by HRSA’s FORHP.

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Birth Care for Rural/Urban American Indians While American Indians (AIs) constitute a substantial minority population in many rural areas,...
Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women

While American Indians (AIs) constitute a substantial minority population in many rural areas, population-based research on the health status of AI women and infants is limited. This study used the National Linked Birth Death Certificate Data Set for 1989 and 1991 to compare the perinatal risk factors, prenatal care use, birth outcomes, and infant death rates of rural AIs, urban AIs, and whites. Results from this study should help administrators and policy makers to better understand the health care needs of this population, as well as the targeted interventions needed to improve birth outcomes and infant health status. Funded by HRSA’s ORHP.

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BBA and Rural Residency Training This national survey examined the proportion of rural-based family medicine residencies across the...
Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study

This national survey examined the proportion of rural-based family medicine residencies across the United States that have ceased operations since 2000, the residency match patterns of existing programs, changing proportions of International Medical Graduates (IMGs) and U.S. Medical Graduates (USMGs), and major issues facing rural residency programs. Funded by HRSA’s FORHP.

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Barriers to Rural Residencies This project examined issues related to establishment and maintenance of residencies and residency...
Barriers to Rural Residencies Project

This project examined issues related to establishment and maintenance of residencies and residency tracks in rural America. The project involved both a literature review and interviews with key informants related to the issues surrounding rural residency programs. While the project emphasized generalist residencies, it was not limited to them. The policy paper discussed issues associated with retaining and starting rural residencies and tracks such as their training cost and clinical implications, credentialing constraints, and staffing problems. Understanding the issues surrounding the establishment of rural residencies is important for federal and state legislators and administrators as they revamp the nation’s graduate medical education system. Funded by HRSA’s ORHP.

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APRN Distribution in the U.S. This study analyzed 2010 Centers for Medicare and Medicaid Services' National Provider Identifier...
Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.

This study analyzed 2010 Centers for Medicare and Medicaid Services’ National Provider Identifier (NPI) records to assess the usefulness of the dataset to describe APRN distribution across the United States. There were adequate NPI data to describe urban and rural location of certified registered nurse anesthetists (CRNAs) and nurse practitioners (NPs) in the U.S. and relative per capita supply. Practice location was estimated by linking Rural-Urban Commuting Area codes to NPI provider ZIP codes. Chi-square testing examined provider supply by geographic locations. Multivariate hierarchical regression testing identified whether rural practice location was related to practice autonomy, per capita provider supply, or gender. Funded by the American Nurses Association.

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Ambulatory Care for Rural Elderly Diabetes is a common serious chronic disease where careful clinical monitoring can improve the...
Ambulatory Care and the Rural Elderly

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...
Community Colleges’ Contributions to the Education of Allied Health Professionals in Rural Areas of the United States

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...
Community Colleges' Contributions to the Education of Allied Health Professionals in Rural Areas of the United States

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Aging Rural Physician Workforce This study identifies rural locations with high proportions of generalist physicians nearing...
The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?

This study identifies rural locations with high proportions of generalist physicians nearing retirement age. As fewer young physicians choose generalist careers, the retirement of older physicians may place additional strain on rural generalist supply. This study quantifies the extent to which rural generalist physician shortages may be exacerbated by physician retirement, focusing on known shortage locations. The study used data from the American Medical Association and American Osteopathic Association 2005 Masterfiles. This study was funded by HRSA’s Office of Rural Health Policy.

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Access to and Outcomes of Obstetric Care Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical...
Relationship Between Access to Obstetrical Care and Process and Outcome of Care

Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical care in rural communities and birth outcomes (see working paper #4). The Obstetrical Process and Outcome of Care Study compared rural versus obstetrical care and outcomes from birth certificates. This study examined the relationship between access to and availability of care (number of local providers available who provide obstetrical care and who care for pregnant Medicaid women) and quality and cost of care. Sources of data included Washington State birth certificates and hospital discharge abstracts, supplemented with information on hospitals, communities, and provider supply. Findings from this study further illuminate the connection between poor geographic access, Medicaid access, and poor quality care.

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2004 Rural-Urban Commuting Areas (V2) This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that...
Introduction to and Description of the 2004 (Version 2) Rural-Urban Commuting Areas (RUCAs)

This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that defines rural and urban based on Census Bureau definitions and work commuting patterns. The RUCA taxonomy is a tool based on the sizes of cities and towns and their functional relationships as reflected by commuter patterns. Funded by HRSA’s FORHP.

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