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WWAMI Rural Health Research Center (RHRC)
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Authors	Title	Published by	Date	Article link	Related Studies
Oster NV, Baldwin LM, Justis P, Marchand L, Shearer J, Weng K, Patterson DG	Palliative Care Challenges and Solutions in Rural U.S. Communities	WWAMI Rural Health Research Center, University of Washington	09-05-2024	Policy Brief	Palliative Care in the Rural U.S.	Palliative care (PC) is interdisciplinary care to increase the comfort and quality of life for patients with serious illness, including providing physical, emotional, social, and spiritual care for patients and their caregivers. Rural patients face unique challenges PC, including traveling long distances to access care, lack of transportation, lack of PC health care professionals and resources, limited availability of PC, and cultural and social differences that may affect care. This study sought to describe the availability of PC services in rural communities compared to urban communities and identify novel solutions for providing this essential care to rural communities. This mix-methods study included an analysis of two surveys and qualitative interviews with administrators of small, rural hospitals that offered PC services. The study found that a smaller proportion of rural hospitals (69.1%) vs. urban hospitals (75.9%) reported they provided PC services. PC services were inequitably distributed across rural counties according to socioeconomic and racial composition, with counties without PC services having higher poverty rates, lower levels of education, and higher proportions of Black and American Indian/Alaska Native populations. In the survey of rural hospitals, more than one-third (37.3%) reported that accessing PC services was somewhat or very difficult for patients in their communities. The most frequently reported barriers to providing PC services included dispersed geography (78.2%), inadequate PC workforce (73.0%), and inadequate PC workforce training (69.2%). Interviewees at small, rural hospitals reported that key facilitators for offering PC services included community collaboration, the availability of informal support networks, staff willingness to develop and employ innovative methods to deliver services, and affiliations with larger urban health care systems that can offer resources and support. Access to Care Complete National Reports and Briefs RHRC
Andrilla CHA, Woolcock SC, Meyers K, Patterson DG	Expanding the opioid use disorder medication treatment workforce in rural communities through the RCORP initiative	J Rural Health	07-25-2024	URL	N/A	The Rural Communities Opioid Response Program (RCORP) was funded to help rural communities improve prevention, treatment, and recovery services for Opioid Use Disorder (OUD), including increasing the supply of clinicians with a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine, which was required before 2023. This research investigates the impact of RCORP funding on the supply of DEA-waivered clinicians in rural communities. Journal Article
Mroz TM, Garberson LA, Andrilla CHA, Patterson DG	Estimated Impacts of Multiple Payment Policies on Rural-Serving Home Health Agencies	WWAMI Rural Health Research Center, University of Washington	07-09-2024	Report	Examining the Potential Impact of Multiple Payment Policies on Rural versus Urban Home Health Agencies	This study estimated the potential impacts on rural-serving home health agencies (HHAs) of three recent Medicare payment policy changes: • The Patient Driven Groupings Model (PDGM) was implemented in 2020 and replaced Medicare’s original prospective payment system with a new model that focuses more on patients’ clinical characteristics at home health admission and uses shorter 30-day payment periods compared to the prior model. • Rural add-on payments, which provided percentage-based increases in payments made to HHAs for serving rural beneficiaries, were revised based on county-level service utilization and population density starting in 2019, and then gradually decreased annually through 2022 before sunsetting at the end of 2023. • The Home Health Value Based Purchasing (HHVBP) model, which provides a percentage increase or decrease in all payments to HHAs based on overall quality scores, was launched as a demonstration in nine states in 2016 and expanded nationwide in 2022. News Reports and Briefs RHRC RHRC Home
Andrilla CHA, Patterson DG, Burchim SE, Dunn JA, Keppel GA, Miller SG, Woolcock SC	Rural Communities Opioids Response Program (RCORP)	WWAMI Rural Health Research Center, University of Washington	02-22-2024	An Assessment of the Individual TA Tracker RCORP 2022 Reverse Site Visit RCORP Grantees’ Sustained Challenges, Technical Assistance Needs, and Technical Assistance Provided ... View more	N/A	The Health Resources & Services Administration’s Federal Office of Rural Health Policy funded the Rural Communities Opioids Response Program (RCORP) to help rural communities across the U.S. to increase prevention, treatment, and recovery services for rural residents with substance use disorder. As part of the initiative, JBS International was funded to provide technical assistance (TA) to grantee recipients to support their grant activities. The WWAMI Rural Health Research Center conducted an evaluation of the TA provided to RCORP grantees from March 1, 2022 – September 30, 2023. The WWAMI RHRC evaluation of TA resulted in reports and briefs covering multiple types of TA, including TA events, and feedback from grantees on the TA they received. This body of work offers lessons on how to support rural communities working to address the opioid epidemic. Lead Researcher Holly Andrilla, MS Status Complete Reports and Briefs RHRC
Larson EH, Oster NV, Jopson AD, Andrilla CHA, Pollack SW, Patterson DG	Routes to Rural Readiness: Enhancing Clinical Training Experiences for Physician Assistants	J Physician Assist Educ	09-01-2023	URL	N/A	Rural provider shortages in primary care can be alleviated by encouraging and supporting physician assistants (PAs) to practice in rural areas. This study surveyed and interviewed 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. Journal Article RuralPREP
Longenecker R, Oster NV, Peterson L, Andrilla CHA, Schmitz DF, Evans DV, Morgan ZJ, Pollack SW, Patterson DG	A Match Made in Rural: Interpreting Match Rates and Exploring Best Practices	Family Medicine	04-01-2023	URL	N/A	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. Journal Article RuralPREP
Schmitz DF, Casapulla S, Patterson DG, Longenecker R	Building Rural Primary Care Research by Connecting Rural Programs	Annals of Family Medicine	02-01-2023	URL	N/A	This article describes a Scholarly Intensive for Rural Programs to connect rural health professions education programs within a community of practice focused on promoting scholarly activity and research in rural primary health care, education, and training. This novel strategy brings enduring scholarly resources to rural programs and the communities they serve, teaches skills to health profession trainees and rurally located faculty, empowers clinical practices and educational programs, and supports the discovery of evidence that can improve the health of rural people. Journal Article RuralPREP
Cole A, Andrilla CHA, Patterson DG, Davidson S, Mendoza J	Measuring the Impact of the COVID-19 Pandemic on Health Behaviors and Health Care Utilization in Rural and Urban Patients with Cancer and Cancer Survivors	Cancer Research Communications	02-07-2023	URL	Impact of COVID-19 on Cancer-Related Health Behaviors in Rural Cancer Patients and Rural Cancer Survivors	Health care access and health behaviors differ between those living in urban and rural communities and contribute to inequitable cancer health outcomes. The COVID-19 pandemic led to significant disruptions in daily life and health care delivery. This cross-sectional survey aimed to measure the impact of the COVID-19 pandemic on the health behaviors of patients with cancer and survivors, comparing outcomes for urban and rural respondents. Access to Care Hospitals Journal Article RHRC Washington
Patterson DG, Shipman SA, Pollack SW, Andrilla CHA, Schmitz D, Evans D, Peterson LE, Longenecker R	Growing a Rural Family Physician Workforce: The Contributions of Rural Background and Rural Place of Residency Training	Health Serv Res	05-09-2023	URL	Are Family Physicians Trained in Small Rural Residencies of Comparable Quality to Family Physicians Overall?	This study sought to determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians. Family physicians from a rural background were more likely to choose rural practice than those from an urban background, but rural training was an even stronger predictor of rural practice. Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians. Journal Article RHRC RHRC Home RuralPREP
Fredrickson E, Evans DV, Woolcock S, Andrilla CHA, Garberson LA, Patterson DG	Understanding and Overcoming Barriers to Rural Obstetric Training for Family Physicians	Fam Med	06-01-2023	URL	Overcoming Barriers to Providing Rural Obstetrical Training for Physicians
Woolcock S, Fredrickson E, Evans DV, Andrilla CHA, Garberson LA, Patterson DG	Understanding and Overcoming Barriers to Rural Training in Family Medicine Obstetrics Fellowships	WWAMI Rural Health Research Center, University of Washington	06-01-2023	Policy Brief	Overcoming Barriers to Providing Rural Obstetrical Training for Physicians	Many rural communities rely on family physicians for obstetrical (OB) care. Family medicine (FM) residencies vary in the breadth and depth of OB training, so many family physicians interested in practicing OB in rural areas seek additional fellowship training. This study aimed to describe characteristics of rurally oriented FM OB fellowships and challenges these programs face in providing OB training. This policy brief describes the results of a survey on the characteristics and challenges faced by rurally oriented family medicine obstetrics fellowship programs. All survey respondents reported their programs had a mission to train family physicians for rural practice, yet less than one-third of programs reported they required rural training. Nearly all fellowships reported training graduates to provide prenatal and delivery care, including vaginal deliveries, C-sections, gynecology procedures, and OB ultrasound. The most frequently reported major challenges to providing rural OB training were community factors that included competition with other OB providers, declining OB patient populations, and lack of community awareness of family physicians’ scope of practice. Policy efforts are needed to strengthen rural training opportunities for OB-inclined family medicine trainees. Complete National Physicians Reports and Briefs RHRC
Pollack SW, Andrilla CHA, Peterson LE, Morgan ZJ, Longenecker R, Schmitz D, Evans D, DG Patterson	Rural versus urban family medicine residency scope of training and practice	Fam Med	01-26-2023	URL	Are Family Physicians Trained in Small Rural Residencies of Comparable Quality to Family Physicians Overall?	Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates. RHRC RuralPREP
Peterson LE, Morgan ZJ, Andrilla CHA, Pollack SW, Longenecker R, Schmitz D, Evans D, Patterson DG	Academic achievement and competency in rural and urban family medicine residents	Fam Med	01-26-2023	URL	Are Family Physicians Trained in Small Rural Residencies of Comparable Quality to Family Physicians Overall?	The quality of training in rural family medicine (FM) residencies has been questioned. This study assesses differences in academic performance between rural and urban FM residencies. RHRC RuralPREP
Kaplan L, Pollack SM, Skillman SM, Patterson DG	Is Being There Enough? Postgraduate Nurse Practitioner Residencies in Rural Primary Care	J Rural Health	11-22-2022	URL	N/A	Little research has been conducted on the outcomes of postgraduate nurse practitioner (NP) programs (referred to as residencies), particularly those located in rural communities. This study examined the purpose and characteristics of rural NP residencies that aim to promote the successful recruitment, transition, and retention of NPs in rural primary care practice. Journal Article RuralPREP
Andrilla CHA, Woolcock SC, Garberson LA, Patterson DG	Changes in the Supply and Rural-Urban Distribution of Selected Behavioral Health Providers	WWAMI Rural Health Research Center, University of Washington	10-03-2022	Counselors Psychiatric Nurse Practitioners Psychiatrists Psychologists Social Workers	Trends in Health Workforce Supply in the Rural U.S.	In 2020, an estimated 12.7 million rural adults suffered from a behavioral health concern – mental illness, substance use disorder, or other psychiatric conditions. Accessing behavioral health care is particularly challenging for rural communities due to disparities in the distribution of behavioral health care providers. These data briefs describe the trends in the supply and distribution of selected behavioral health providers in the rural vs urban U.S. nationally, and within Census Divisions. The behavioral health providers examined include psychiatrists, psychologists, psychiatric nurse practitioners, social workers, and counselors. There were fewer per capita behavioral health providers in rural vs urban counties. There were also disparities in the supply of providers across rural categories and Census Divisions. While the per capita supply of psychiatrists declined over the past decade, the supply of psychologists, psychiatric nurse practitioners, social workers, and counselors increased in both rural and urban counties. Reports and Briefs RHRC
Patterson DG, Nudell N, Garberson LA, Andrilla CHA	Prehospital Emergency Medical Services Personnel: Comparing Rural and Urban Professional Experience and Provision of Evidence-Based Care	WWAMI Rural Health Research Center, University of Washington	05-01-2022	Policy Brief	Prehospital Emergency Medical Services Personnel: Comparing Rural and Urban Provider Experience and Provision of Evidence-based Care	Rural populations frequently reside greater distances from emergency rooms, creating a need for timely and evidence-based pre-hospital emergency medical services (EMS). Longer distances to definitive care mean that rural EMS professionals often require greater skill levels than their urban counterparts. Yet rural EMS systems tend to have fewer resources, rely more heavily on volunteer staff, and have fewer personnel trained at higher levels. This study describes the relationship between prehospital emergency medical services (EMS) providers’ accumulated experience and provision of evidence-based care for rural and urban populations. Results can inform policies for ensuring that rural populations have timely and appropriate access to high-quality prehospital emergency care. Complete National Reports and Briefs RHRC RHRC Home
Mroz TM, Garberson LA, Andrilla CHA, Patterson DG	Quality of Skilled Nursing Facilities Serving Rural Medicare Beneficiaries	WWAMI Rural Health Research Center, University of Washington	02-24-2022	Policy Brief	Post-acute Care Quality for Rural Medicare Beneficiaries	Rural Medicare beneficiaries receive care from skilled nursing facilities (SNFs) located in both rural and urban communities. Over one-fifth of urban SNFs have patient populations consisting of 10% or more rural beneficiaries and can be considered rural-serving along with rural SNFs. In this policy brief, we examine variation in Medicare star ratings for SNFs by rural-serving status. While overall star ratings and staffing star ratings were not significantly associated with rural-serving status, rural SNFs and rural-serving urban SNFs were significantly less likely to have high quality star ratings compared to non-rural-serving urban SNFs. However, SNFs in isolated small rural communities were more likely to have high survey star ratings compared to non-rural-serving urban SNFs. The relationship between SNF quality and rural-serving status is not consistent across the different types of star ratings. Complete Other Work Settings Reports and Briefs RHRC
Mroz TM, Garberson LA, Andrilla CHA, Patterson DG	Quality of Home Health Agencies Serving Rural Medicare Beneficiaries	WWAMI Rural Health Research Center, University of Washington	02-24-2022	Policy Brief	Post-acute Care Quality for Rural Medicare Beneficiaries	Rural Medicare beneficiaries receive care from home health agencies (HHAs) located in both rural and urban communities. Over one-fifth of urban HHAs have patient populations consisting of 10% or more rural beneficiaries and can be considered rural-serving along with rural HHAs. In this policy brief, we examine variation in Medicare star ratings for HHAs by rural-serving status. While the quality of patient care star ratings was not significantly associated with rural-serving status, patient experience star ratings were higher among rural-serving HHAs. Rural-serving urban HHAs were almost twice as likely to have high patient experience star ratings compared to non-rural-serving urban HHAs. HHAs located in large, small, and isolated small rural communities were even more likely to have high patient experience star ratings compared to non-rural-serving urban SNFs, and the likelihood of high ratings increased as rurality increased. Quality of patient care and patient experience star ratings are capturing different domains of quality and rural-serving HHAs outperform non-rural-serving HHAs on patient experience star ratings. Complete Other Work Settings Reports and Briefs RHRC
Evans DV, Andrilla CHA, Yung, R, Patterson DG	The association of rurality and breast cancer stage at diagnosis: a national study of the SEER cancer registry	WWAMI Rural Health Research Center, University of Washington	10-20-2021	Policy Brief	Do Rural Breast and Colorectal Cancer Patients Present at More Advanced Disease Stages than their Urban Counterparts?	Patients from rural areas have lower breast cancer screening rates than urban patients. We found that a greater proportion of rural patients received an initial breast cancer diagnosis at a late stage compared with urban patients and that patients living in remote small rural counties had the highest rate of late-stage breast cancer at diagnosis. Breast cancer survival is known to be worse for rural patients compared to urban, and late stage at diagnosis may be a contributing factor. These disparities are longstanding and suggest areas for further research, advocacy, policy changes, and patient education.  Further study is needed to identify appropriate screening availability in rural areas and the burdens that travel presents for patients where screening is not available. News Reports and Briefs RHRC cancer disease prevention health disparities health equity Health promotion Healthcare access minority health rural health disparaties Women
Mroz TM, Frogner BK, Patterson DG	The impact of Medicare’s rural add-on payments on supply of home health agencies serving rural counties	Health Affairs	06-01-2020	URL	N/A	Intermittently since 2001, Medicare has provided a percentage increase over standard payments to home health agencies that serve rural beneficiaries. Yet the effect of rural add-on payments on the supply of home health agencies that serve rural communities is unknown. Taking advantage of the pseudo–natural experiment created by varying rural add-on payment amounts over time, we used data from Home Health Compare to examine how the payments affected the number of home health agencies serving rural counties. Our results suggest that while supply changes are similar in rural counties adjacent to urban areas and in urban counties regardless of add-on payments, only higher add-on payments (of 5 percent or 10 percent) keep supply changes in rural counties not adjacent to urban areas on pace with those in urban counties. Our findings support the recent shift from broadly applied to targeted rural add-on payments but raise questions about the effects of the amount and eventual sunset of these payments on the supply of home health agencies serving remote rural communities. CHWS Journal Article RHRC
Larson EH, Andrilla CHA, Garberson LA, Evans DV	Geographic access to health care for rural Medicare beneficiaries: a national study	WWAMI Rural Health Research Center, University of Washington	09-07-2021	Policy Brief	Geographic Access to Health Care for Rural Medicare Beneficiaries: An Update and National Look	Rural residents travel farther for medical services and generally have fewer visits with medical specialists than their urban counterparts. These issues can pose serious challenges for older Medicare beneficiaries. This study compared, at a national and census division level, total number of visits received, where rural and urban Medicare beneficiaries received care, which types of providers were seen, and how far beneficiaries traveled to obtain care. In 2014, rural beneficiaries received slightly more total visits than urban beneficiaries. Rural beneficiaries received the majority of their visits (51.7%) from generalist physicians, nurse practitioners and physician assistants compared to 38.1% among urban beneficiaries. Median one-way travel times for rural residents from isolated small rural areas were particularly long, often exceeding one hour for serious conditions such as cancer and ischemic heart disease. Overcoming problems with geographic access to care issues will require a rurally committed generalist workforce that offers a wide range of services and assures efficient access to specialist services when necessary. Complete Reports and Briefs RHRC aging chronic disease Health Services Healthcare workforce Medicare
Larson EH, Andrilla CHA, Garberson LA, Evans DV	Geographic access to health care for rural Medicare beneficiaries in five states: an update	WWAMI Rural Health Research Center, University of Washington	04-01-2021	Policy Brief	Geographic Access to Health Care for Rural Medicare Beneficiaries: An Update and National Look	Using data from five states (AK, ID, NC, SC, WA), this study describes the mix of providers caring for rural Medicare beneficiaries, the quantity of care received, and how far rural beneficiaries traveled for care for several selected conditions in 2014. Results are also compared with a similar study of the same states that used data from 1998. Reports and Briefs RHRC aging Health Care Services Healthcare access Medicare Nurse and nurse practitioners nurses physician Physicians Assistant
Andrilla CHA, Patterson DG	Tracking the geographic distribution and growth of clinicians with a DEA waiver to prescribe buprenorphine to treat opioid use disorder	Journal of Rural Health	03-18-2021	URL	What is the Geographic Distribution of the Workforce with a DEA Waiver to Prescribe Buprenorphine?	Purpose Buprenorphine is an effective medication treatment for opioid use disorder (MOUD) but access is difficult for patients, especially in rural locations. To improve access, legislation, including the Comprehensive Addiction and Recovery Act (2016) and the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act (2018), extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat opioid use disorder (OUD) to numerous types of clinicians. This study updates the distribution of waivered clinicians as of July 2020 and notes regional and geographic differences. The number of DEA‐waivered clinicians more than doubled between December 2017 and July 2020 from 37,869 to 98,344. The availability of a clinician with a DEA waiver to provide MOUD 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 lacked one. There were also significant differences in access by the US Census Division. Conclusions Overall, MOUD access has improved, but small rural communities still experience treatment disparities and there is significant regional variation. Contact: Holly Andrilla, MS Journal Article RHRC buprenorphine medication-based treatment opioid treatment opioid use disorder rural health
Mroz TM, Garberson LA, Andrilla CHA, Skillman SM, Larson EH, Patterson DG	Post-acute care trajectories for rural Medicare beneficiaries: planned versus actual hospital discharges to skilled nursing facilities and home health agencies	WWAMI Rural Health Research Center, University of Washington	03-24-2021	Policy Brief	Post-acute Care Trajectories for Rural Medicare Beneficiaries	This policy brief describes trajectories for rural Medicare beneficiaries following hospital discharge including differences between planned and actual discharge to skilled nursing facilities and home health agencies. Over 40% of beneficiaries for whom home health care was indicated did not receive care from a home health agency. Hospitals Nursing Reports and Briefs RHRC
Larson EH, Andrilla CHA, Kearney J, Garberson LA, Patterson DG	The distribution of the general surgery workforce in rural and urban America in 2019	WWAMI Rural Health Research Center, University of Washington	03-01-2021	Policy Brief	The Current Distribution of the General Surgery Workforce in Rural America	General surgeons play a crucial role in rural health care in the U.S. Rural general surgeons decrease the need for patients to travel for routine surgery, provide backup to rural primary care providers in emergency care, obstetrics, and orthopedics, and contribute substantially to the financial health of rural hospitals. Between 2001 and 2019, the per capita supply of general surgeons in the U.S. decreased by 18.0% overall and by 29.1% in rural areas. Rural general surgeons are older than their urban counterparts. In 2019, 59.4% of the general surgeons in small/isolated rural areas were 50 years of age and older, compared to 48.8% in urban areas. While the proportion of women in the general surgery workforce rose from 10.6% in 2001 to 26.1% in 2019, this proportion is smaller in rural areas, only 19.7% in 2019. Long-term preservation of rural surgical services will require concerted efforts by medical school educators, residency directors, and rural advocates to promote and sustain interest in rural general surgery among medical students and surgical residents, especially women. Contact: Eric Larson, PhD Access to Care Physicians Reports and Briefs RHRC RHRC Home
Andrilla CHA, Garberson LA, Larson EH, Patterson DG, Quigley TF	Comparing the health workforce provider mix and the distance travelled for mental health services by rural and urban Medicare beneficiaries	Journal of Rural Health	08-18-2020	URL	Who Provides Mental Health Services to Rural Medicare Beneficiaries?	To describe the mix of health professionals who care for rural and urban seniors suffering from mood and/or anxiety disorders, the quantity of services they receive, and to understand where beneficiaries receive care for mood and/or anxiety disorders and the distance and time they travel for care. Journal Article News RHRC
Patterson DG, Andrilla CHA, Garberson LA	The supply and rural-urban distribution of the obstetrical care workforce in the U.S.	WWAMI Rural Health Research Center, University of Washington	06-24-2020	Policy Brief	The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S.	Monitoring the supply of the obstetrical (OB) care workforce is important for identifying areas that may lack OB care access. This brief describes the supply and geographic distribution of obstetricians, advanced practice midwives, midwives (not advanced practice), and family physicians in rural versus urban counties. Our findings reveal significant geographic disparities in OB clinician supply. News Reports and Briefs RHRC
Larson EH, Andrilla CHA, Garberson LA	Supply and distribution of the primary care workforce in rural America: 2019	WWAMI Rural Health Research Center, University of Washington	06-24-2020	Policy Brief	The Supply and Distribution of the Primary Care Health Workforce in Rural America	Maintaining an adequate supply of primary care providers in the United States is one of the key challenges in rural health care. This study examines the 2019 supply and geographic distribution of primary care physicians, nurse practitioners, and physician assistants across rural areas of the United States. News Reports and Briefs RHRC
Larson EH, Andrilla CHA, Garberson LA	Supply and distribution of the primary care workforce in rural America: a state-level analysis	WWAMI Rural Health Research Center, University of Washington	06-24-2020	Data Brief Alabama Alaska Arizona ... View more	The Supply and Distribution of the Primary Care Health Workforce in Rural America	Maintaining an adequate supply of primary care providers in the United States is one of the key challenges in rural health care. This study examines the 2019 supply and geographic distribution of primary care physicians, nurse practitioners, and physician assistants across rural areas of the United States. News Reports and Briefs RHRC
Patterson DG, Andrilla CHA, Garberson LA	The supply and rural-urban distribution of the obstetrical care workforce in the U.S.: a state-level analysis	WWAMI Rural Health Research Center, University of Washington	06-01-2020	Data Brief Alabama Alaska Arizona Arkansas California Colorado ... View more	The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S.	Monitoring the supply of the obstetrical (OB) care workforce is important for identifying areas that may lack OB care access. This brief describes the supply and geographic distribution of obstetricians, advanced practice midwives, midwives (not advanced practice), and family physicians in rural versus urban counties. Our findings reveal significant geographic disparities in OB clinician supply. Reports and Briefs RHRC
Al Achkar M, Bennett IM, Chwastiak L, Hoeft T, Normoyle T, Vredevoogd M, Patterson DG	Telepsychiatric consultation as a training and workforce development strategy for rural primary care	Ann Fam Med	09-01-2020	URL	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. 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. 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. Contact: Ian Bennett MD Journal Article RuralPREP
Longenecker RL, Andrilla CHA, Jopson AD, Evans DV, Schmitz D, Larson EH, Patterson DG	Pipelines to pathways: medical school commitment to producing a rural workforce	J Rural Health	11-26-2020	URL	Measuring the Commitment of Health Professions Schools to Rural Primary Care	Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. 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. Contact: Randall Longenecker MD Journal Article RuralPREP
Kaplan L, Pollack SW, Skillman S, Patterson DG	Factors that encourage and support advanced practice registered nurses to work in rural and safety-net settings	J Health Care Poor Underserved	11-01-2020	URL	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. Research regarding effective strategies for recruiting and retaining rural or safety-net providers often focuses on physicians or combinations of health care professionals. We 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. In-Progress RuralPREP
Kaplan L, Pollack SW, Skillman SM, Patterson DG	NP program efforts promoting transition to rural practice	The Nurse Practitioner	10-01-2020	URL	Routes to Rural Readiness: Enhancing Clinical Training Experiences for Nurse Practitioner Practice in Rural Primary Care	This article presents the results of a study that 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. 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. Journal Article RuralPREP
Jopson AD, Pollack SW, Schmitz DF, Thompson MJ, Harris D, Bateman M, Evans DV, Patterson DG	Promoting health careers among rural K–16 students: a mixed-method study to describe pathway programs	J Health Care Poor Underserved	11-01-2020	URL	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 US 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. 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. Journal Article RuralPREP
Schmitz DF, Evans DV, Andrilla CHA, Jopson AD, Longenecker RL, Patterson DG	Challenges and best practices for implementing rurally targeted admissions in U.S. medical schools	Journal of Health Care for the Poor Underserved	11-25-2020	URL	Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission	Student attributes can predict future rural practice, but little is known about how medical schools use these factors in admissions. This mixed-methods study examined admissions strategies to recruit and select students likely to practice rurally. Admissions personnel at U.S. allopathic and osteopathic medical schools were surveyed about rurally targeted admissions. Personnel from selected schools were interviewed to understand further targeted admissions practices. Among 185 medical schools, 133 (71.8%) responded. Schools engaged with students from four-year universities through career exploration (89.9%), admissions preparation (57.7%), academic enhancement (47.7%), and articulation agreements (42.9%). Applicant selection practices included preferential scoring in screening (38.2%) and admissions decisions (30.0%), modified MCAT (21.4%) and GPA cutoffs (18.8%), and reserved class slots (20.2%). Personnel from 10 schools identified key themes of motivations, resources, challenges, and recommendations. Understanding how schools identify and admit rurally inclined students is a first step in identifying best practices for addressing rural workforce gaps. 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. Contact: Davis Patterson PhD Journal Article RuralPREP
Evans DV, Jopson AD, Andrilla CA, Longenecker RL, Patterson DG	Targeted medical school admissions: a strategic process for meeting our social mission	Fam Med	07-31-2020	URL	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 inadequacies in primary care or underserved settings. While there is substantial evidence that student attributes predict practice specialty and location, little is known about how schools use these factors in admissions processes. We sought to describe admissions strategies to recruit students likely to practice in primary care or underserved settings. 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. Journal Article RuralPREP admission primary care special populations
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Wong JL, Larson EH	Variation in use of home health care among fee-for-service Medicare beneficiaries by rural-urban status and geographic region: assessing the potential for unmet need	WWAMI Rural Health Research Center	02-01-2020	Policy Brief	Assessing Potential Unmet Need for Home Health Care in Rural Areas	While the vast majority of Medicare beneficiaries live in areas served by at least one home health agency, recent studies suggest there are differences in access to home health care between urban and rural areas. When providing care in large, rural service areas with low concentrations of patients, home health agencies face different challenges than their urban counterparts, such as greater travel and time costs. Reports and Briefs RHRC
Patterson DG, Schmitz D, Longenecker RL	Family medicine rural training track residencies: risks and resilience	Family Medicine	09-01-2019	URL	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education	Background and Objectives: Family medicine rural training track (RTT) residency programs produce a higher proportion of graduates who choose rural practice than other programs, yet RTTs face continuing threats to their existence. This study sought to understand threats to RTT sustainability and resilience factors that enable RTTs to thrive. Methods: In 2014 and 2015, the authors conducted semistructured interviews of 21 RTT leaders representing two closed programs and 22 functioning programs. Interview topics included program strengths providing resilience and sustainability, risk factors for closure or vulnerabilities threatening sustainability, and advice for other RTTs. The authors performed a content analysis, coding pertinent themes in all interview data. Results: From the top three assets, risks, and advice that respondents offered, the following nine themes emerged, in order from most to least mentioned: leadership, faculty and teaching resources, program support, finances, resident recruitment, program attributes, program mission, political and environmental context, and patient-related clinical experiences. Interviewees frequently reported multifactorial causes for RTT sustainability or closure. Conclusions: Numerous factors identified, such as distance, can operate as positive or negative influences for program resilience, depending on place and context. Resilience depends on multiple forms of social capital, including robust networks among individuals and various communities: the local population and patients, local health care providers, residency faculty, and RTTs in general. The small size and remoteness of RTTs make them vulnerable to multiple challenges in finances, regulations, and accreditation, requiring program adaptability and suggesting the need for flexibility in the policies that govern them. Journal Article National Physicians RHRC
Andrilla CHA, Jones KC, Patterson DG	Prescribing practices of nurse practitioners and physician assistants waivered to prescribe buprenorphine and the barriers they experience prescribing buprenorphine	Journal of Rural Health	10-25-2019	URL	Understanding the Prescribing Practices of Rural Nurse Practitioners and Physician Assistants with a DEA Waiver to Prescribe Buprenorphine	Background: In 2016, the Comprehensive Addiction Recovery Act permitted nurse practitioners (NPs) and physician assistants (PAs) to obtain a waiver to prescribe buprenorphine to treat opioid use disorder(OUD), with the goal of increasing access to this treatment. This study’s purpose was to describe the buprenorphine prescribing practices of NPs and PAs and compare the barriers rural and urban providers face delivering treatment. Methods: From the October 2018 Drug Enforcement Administration list of providers with the waiver to prescribe buprenorphine, all rural NPs and PAs (1,057) and a random sample of 500 urban NPs and PAs were surveyed. The questionnaire queried respondents about demographics, prescribing practices, practice characteristics, reimbursement policies, and barriers to prescribing buprenorphine to treat OUD. Results: Of the waivered NPs and PAs, 80.3% reported having prescribed buprenorphine and 71.1% said they were currently accepting new patients with OUD. Providers with the 30-patient waiver were treating, on average, 13.2 patients; 37.0% were not treating any patients. The most common barrier, cited by half of providers, was concerns about diversion/medication misuse. More rural providers indicated lack of specialty backup and mental health providers as a barrier than urban providers. Never-prescribers and former prescribers reported 6 barriers at significantly higher rates than did current prescribers. More rural providers accepted Medicaid and cash reimbursement than urban providers. Conclusions: NPs and PAs face many of the same barriers to providing buprenorphine as physicians have reported. Interventions to address these barriers have the potential to benefit all providers with the waiver to prescribe buprenorphine. Journal Article RHRC buprenorphine medication-based treatment opiate dependent opiate substitution treatment rural health
Patterson DG, Andrilla CHA, Garberson LA	Preparing physicians for rural practice: availability of rural training in rural-centric residency programs	J Grad Med Educ	10-01-2019	URL	What Impact Will Unified GME Accreditation Have on Rural-focused Physician Residencies?	Background. Exposing residents to rural training encourages future rural practice, but unified accreditation of allopathic and osteopathic graduate medical education under one system by 2020 has uncertain implications for rural residency programs. Objective. We describe training locations and rural-specific content of rural-centric residency programs (requiring at least 8 weeks of rurally located training) before this transition. Methods. In 2015, we surveyed residency programs that were rurally located or had rural tracks in 7 specialties and classified training locations as rural or urban using Rural-Urban Commuting Area (RUCA) codes. Results. Of 1849 residencies in anesthesiology, emergency medicine, general surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry, 119 (6%) were rurally located or offered a rural track. Ninety-seven programs (82%) responded to the survey. Thirty-six programs required at least 8 weeks of rural training for some or all residents, and 69% of these rural-centric residencies were urban-based and 53% were osteopathic. Locations were rural for 26% of hospital rotations and 28% of continuity clinics. Many rural-centric programs (35%) reported only urban ZIP codes for required rural block rotations; 54% reported only urban ZIP codes for required rural clinic sessions, and 31% listed only urban ZIP codes in reporting rural full-time training locations. Programs varied widely in coverage of rural-specific training in 6 core competencies. Conclusions. In multiple specialties important for rural health care systems, little rurally located residency training and rural-specific content was available. Substantial proportions of training locations reported to be rural were actually urban according to a common rural definition. Complete Journal Article News Physicians RHRC RHRC Home
Andrilla CHA, Moore TE, Wong KM, Evans DV	Investigating the impact of geographic location on colorectal cancer stage at diagnosis: a national study of the SEER cancer registry	The Journal of Rural Health	08-27-2019	URL	Do Rural Breast and Colorectal Cancer Patients Present at More Advanced Disease Stages than their Urban Counterparts?	We found that early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examined the extent to which United States’ rural residents present at a more advanced stage of CRC compared to nonrural residents. Complete Journal Article RHRC cancer colorectal crc rural
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Wong JL, Larson EH	Differences in care processes between community-entry versus post-acute home health for rural Medicare beneficiaries	WWAMI Rural Health Research Center	04-04-2019	PB #166	Diverging Populations Served by the Medicare Home Health Benefit: Comparison of Post-acute vs. Community-entry Home Health in Rural Areas
Andrilla CHA, Moore TE, Patterson DG	Overcoming barriers to prescribing buprenorphine for the treatment of opioid use disorder: recommendations from rural physicians	J Rural Health	01-01-2019	URL	What are Best Practices for Providing Buprenorphine Maintenance Treatment in Rural Primary Care?	Purpose: The United States is in the midst of a severe opioid use disorder epidemic. Buprenorphine is an effective office-based treatment that can be prescribed by physicians, nurse practitioners, and physician assistants with a Drug Enforcement Administration (DEA) waiver. However, many providers report barriers that keep them from either getting a DEA waiver or fully using it. The study team interviewed rural physicians successfully prescribing buprenorphine to identify strategies for overcoming commonly cited barriers for providing this service. Methods: Interview candidates were randomly selected from a list of rurally located physicians with a DEA waiver to prescribe buprenorphine who reported treating high numbers of patients on a 2016 survey. Forty-three rural physicians, who were prescribing buprenorphine to a high number of patients, were interviewed about how they overcame prescribing barriers previously identified in that survey. Findings: Interviewed physicians reported numerous ways to overcome common barriers to providing buprenorphine treatment in rural areas. Key recommendations included ways to (1) get started and maintain medication-assisted treatment, (2) minimize DEA intrusion and medication diversion, and (3) address the lack of mental health providers and stigma surrounding opioid use disorder (OUD). Overall, physicians found providing this service to be very rewarding. Conclusions: Despite known barriers, rural physicians around the country have been successful in adding buprenorphine treatment to their practices. Nonprescribing providers can learn from the strategies used by successful prescribers to add this service. Journal Article News RHRC buprenorphine medication-assisted treatment opioid treatment opioid use disorder rural health
Andrilla CHA, Moore TE, Patterson DG, Larson EH	Geographic distribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disorder: a 5-year update	Journal of Rural Health	06-20-2018	URL	The Supply of Physicians Waivered to Treat Opioid Addiction in Rural America: Policy Options to Remedy Critical Shortages	PURPOSE: Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier. METHODS: Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012. FINDINGS: The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural). CONCLUSIONS: Overall, MAT access has improved, but rural communities still experience treatment disparities. Journal Article RHRC buprenorphine medication-assisted treatment opioid treatment programs opioid use disorder rural health
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Larson EH	Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care	Home Health Care Services Quarterly	06-25-2018	URL	N/A	Abstract Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies. Journal Article RHRC Health Services home health care Medicare/Medicaid quality of care/evaluation of services rural issues
Andrilla CHA, Coulthard C, Larson EH, Patterson DG, Moore TE	Projected contributions of nurse practitioners and physicians assistants to buprenorphine treatment services for opioid use disorder in rural areas	Medical Care Research and Review	08-09-2018	URL	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	The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities. Journal Article News Nursing RHRC buprenorphine CARA 2016 medication-assisted treatment opioid treatment opioid use disorder rural health
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Wong JL, Larson EH	Different populations served by the Medicare home health benefit: comparison of post-acute versus community-entry home health in rural areas	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-31-2018	Policy Brief 165	Diverging Populations Served by the Medicare Home Health Benefit: Comparison of Post-acute vs. Community-entry Home Health in Rural Areas	Rural, fee-for-service Medicare beneficiaries who are admitted to home health from the community (community-entry) are significantly different from those who are admitted to home health following an inpatient stay (post-acute). Higher rates of community-entry were seen among beneficiaries who were older, female, non-white, living alone, and dually eligible for Medicare and Medicaid, and who had lower clinical severity, lower functional status, more cognitive impairment, and higher need for caregiver assistance for supervision and safety. Wide variation by state exists in rates of community-entry home health episodes for rural beneficiaries, even after controlling for beneficiary characteristics. Maryland had the lowest percentage of community-entry home health episodes as a percentage of all home health episodes (17.6%), while Texas had the highest (38.8%). County-level community characteristics—including rurality, persistent poverty, population loss, number of acute hospital beds, number of skilled nursing facility beds, number of home health agencies, and state-level Medicaid expenditures on home- and community-based services—also have significant but relatively small associations with rates of community-entry compared with state and beneficiary characteristics. Access to Care News Reports and Briefs RHRC RHRC Home Health Services Home health Medicare Post-acute Care
Larson EH, Coulthard C, Andrilla CHA	What makes physician assistant training programs successful at training rural PAs?	Seattle WA: WWAMI Rural Health Research Center, University of Washington	06-01-2018	Policy Brief #164	What Makes Physician Assistant Programs Successful at Training Rural PAs?	Key Findings A survey of United States physician assistant (PA) training programs showed that 57.1% of the responding programs considered training rural PAs to be an important program goal. Of those rurally oriented programs, just over half actively recruited rural students. Fewer than half used rural background as an admission criterion or required clinical training in a rural location. PA training programs that are successful at training PAs who choose rural practice are likely to combine a rural mission, targeted recruitment of rural students, and specific rural clinical training experiences. National News Reports and Briefs RHRC PA physician assistants primary care shortage rural
Andrilla CHA, Coulthard C, Patterson DG	Prescribing practices of rural physicians waivered to prescribe buprenorphine	American Journal of Preventive Medicine	06-01-2018	URL	Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas	Opioid use disorder is a serious public health burden, especially throughout rural America. Although efforts have been made to increase the availability of buprenorphine (an office-based medication-assisted treatment), more than 60% of rural counties in the U.S. lack a physician with a Drug Enforcement Administration waiver to prescribe it. This study surveyed all rural physicians with a Drug Enforcement Administration waiver in 2016 to prescribe buprenorphine for opioid use disorder in the U.S. and asked about physician’s demographics, prescribing practices, and barriers to prescribing buprenorphine for treatment of opioid use disorder. Journal Article News RHRC
Andrilla CHA, Coulthard C, Larson EH, Patterson DG, Garberson LA	Geographic variation in the supply of selected behavioral health providers	American Journal of Preventive Medicine	06-01-2018	URL	Supply and Distribution of the Behavioral Health Workforce in Rural America	Introduction In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows. Methods The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016. Results Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist. Conclusions Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations. Supplement information This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Journal Article News RHRC
Patterson DG	The contributions of international medical graduates to healthcare for rural and underserved populations: a reference list, 2000-2010	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2010	Reference List
Andrilla CHA, Coulthard C, Larson EH	Barriers rural physicians face prescribing buprenorphine for opioid use disorder	Ann Fam Med	07-10-2017	URL	Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas	Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service. Journal Article National News RHRC buprenorphine medication-assisted treatment mental health care opiate addiction opiate substitution treatment opioid treatment programs rural health
Andrilla CHA, Garberson LA, Patterson DG, Larson EH	The supply and distribution of the behavioral health workforce in America: a state-level analysis	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-10-2017	Full Report Alabama Alaska ... View more	Supply and Distribution of the Behavioral Health Workforce in Rural America
Andrilla CHA, Coulthard C, Larson EH	Changes in the supply of physicians with a DEA DATA waiver to prescribe buprenorphine for opioid use disorder	Seattle, WA: WWAMI Rural Health Research Center, University of Washington Data Brief #162	05-01-2017	Data Brief	Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas
Doescher MP, Lee C, Berke EM, Adachi-Mejia AM, Lee CK, Stewart O, Patterson DG, Hurvitz PM, Carlos HA, Duncan GE, Moudon AV	The built environment and utilitarian walking in small U.S. towns	Prev Med	12-01-2014	URL	Small Town Walkability: Measuring the Effect of the Built Environment	Objectives The role of the built environment on walking in rural United States (U.S.) locations is not well characterized. We examined self-reported and measured built environment correlates of walking for utilitarian purposes among adult residents of small rural towns. Methods In 2011–12, we collected telephone survey and geographic data from 2152 adults in 9 small towns from three U.S. regions. We performed mixed-effects logistic regression modeling to examine relationships between built environment measures and utilitarian walking (“any” versus “none”; “high” [≥ 150 min per week] versus “low” [< 150 min per week]) to retail, employment and public transit destinations. Results Walking levels were lower than those reported for populations living in larger metropolitan areas. Environmental factors significantly (p < 0.05) associated with higher odds of utilitarian walking in both models included self-reported presence of crosswalks and pedestrian signals and availability of park/natural recreational areas in the neighborhood, and also objectively measured manufacturing land use. Conclusions Environmental factors associated with utilitarian walking in cities and suburbs were important in small rural towns. Moreover, manufacturing land use was associated with utilitarian walking. Modifying the built environment of small towns could lead to increased walking in a sizeable segment of the U.S. population. Journal Article National RHRC Exercise/physical activity Health promotion Physical environment Prevention rural health Social environment Walking
Doescher M, Lee C, Saelens BE, Lee C, Berke EM, Adachi-Mejia AM, Patterson DG, Moudon AV	Utilitarian and recreational walking among Spanish- and English-speaking Latino adults in micropolitan U.S. towns	Journal of Immigrant and Minority Health	04-01-2016	URL	Small Town Walkability: Measuring the Effect of the Built Environment
Evans D, Patterson DG, Andrilla CHA, Schmitz D, Longenecker R	Do residencies that aim to produce rural family physicians offer relevant training?	Family Medicine	12-01-2016	URL	A Novel Master File of Rural Family Medicine Residency Training: Program Models and Graduate Outcomes	BACKGROUND AND OBJECTIVES: Rural family physicians are in short supply. Rural training can promote rural practice, but the number of family medicine residencies with a rural focus, geographic distribution of training, and training content are poorly understood. This study identified rural-centric family medicine residencies, their training locations, and rurally relevant skills training provided. METHODS: The authors identified family medicine residencies offering rural tracks or in rural locations using FREIDA Online®, the American Osteopathic Association “Opportunities,” and the American College of Osteopathic Family Physicians Residency Finder online databases. Program personnel completed a survey in 2013 about training locations and content. RESULTS: Of 583, 171 (29%) family medicine residencies met inclusion criteria. A total of 131 returned surveys (77%). Fifty-eight programs (44% of respondents) required at least 8 weeks of rural training; results describe these rural-centric programs. Programs reported a mean of 43.6 weeks (SD 49.7) of required rural block rotations. Mean hours per week in required rural continuity clinic sessions were 14.3 (SD 12.2). Thirty-nine percent of block rotation sites, 31% of clinic sites, and 21% of full-time training sites reported as rural were urban according to Rural-Urban Commuting Area codes. Over 90% of programs provided training in orthopedic care and emergency skills. Fewer than 60% provided endoscopy and operative obstetrics training. CONCLUSIONS: Though numerous family medicine residencies seek to produce rural physicians, most programs required fewer than 8 weeks of rural training. Programs varied substantially in rurally located training and rurally relevant content. Students seeking rural training should examine program curricula carefully. Journal Article National Physicians RHRC Curriculum Education Emergency Medical Services Family Practice/education Family/supply & distribution Graduate Humans Internship and Residency/methods Medical Orthopedics/education Osteopathic Physicians Physicians Professional Practice Location Rural Health Services/organization & administration rural track Surveys and Questionnaires
Patterson DG, Coulthard C, Garberson LA, Wingrove G, Larson EH	What Is the potential of community paramedicine to fill rural health care gaps?	J Health Care Poor Underserved	11-01-2016	URL	What Is the Potential of Community Paramedicine to Fill Rural Healthcare Gaps?
Mroz TM, Andrilla CHA, Skillman SM, Garberson LA, Patterson DG	Community factors and outcomes of home health care for high-risk rural Medicare beneficiaries	Seattle, WA: WWAMI Rural Health Center, University of Washington	10-31-2016	Policy Brief	Use of Home Health Services among High Risk Rural Medicare Patients: Patient, Service, and Community Factors Associated with Outcomes of Care
Larson EH, Patterson DG, Garberson LA, Andrilla CHA	Supply and distribution of the behavioral health workforce in rural America	Seattle, WA: WWAMI Rural Health Center, University of Washington	09-29-2016	Data Brief #160	Supply and Distribution of the Behavioral Health Workforce in Rural America
Patterson DG, Andrilla CHA, Larson EH	Graduates of rural-centric family medicine residencies: determinants of rural and urban practice	Seattle, WA: WWAMI Rural Health Center, University of Washington	07-01-2016	Policy Brief	Family Medicine Rural Training Track Graduates: Determinants of Rural and Urban Practice
Patterson DG, Keppel GA, Skillman SM	Conrad 30 waivers for physicians on J-1 visas: state policies, practices, and perspectives	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-10-2016	Final Report	The Influence of State Policies and Practices on J-1 Visa Waiver Physicians' Service in Rural Areas
Patterson DG, Andrilla CHA, Schmitz D, Longenecker R, Evans DV	Outcomes of rural-centric residency training to prepare family medicine physicians for rural practice	Seattle. WA: WWAMI Rural Health Center, University of Washington	03-01-2016	Policy Brief 158	A Novel Master File of Rural Family Medicine Residency Training: Program Models and Graduate Outcomes
Larson EH, Andrilla CHA, Coulthard C, Spetz J	How could nurse practitioners and physician assistants be deployed to provide rural primary care?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2016	Policy Brief	What Are the Possible Impacts of Nurse Practitioners and Physician Assistants on Future Provision of Primary Care in Rural Areas?
Baldwin LM, Andrilla CHA, Porter MP, Rosenblatt RA, Patel S, Doescher MP	Treatment of early-stage prostate cancer among rural and urban patients	Cancer	08-15-2013	URL	Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?	BACKGROUND: Geographic barriers and limited availability of cancer specialists may influence early prostate cancer treatment options for rural men. This study compares receipt of different early prostate cancer treatments between rural and urban patients. METHODS: Using 2004-2006 SEER Limited-Use Data, 51,982 early prostate cancer patients were identified (T1c, T2a, T2b, T2c, T2NOS; no metastases) who were most likely to benefit from definitive treatment (< 75 years old, Gleason score < 8, PSA ≤ 20). Definitive treatmentincluded radical prostatectomy, daily external beam radiation for 5 to 8 weeks, brachytherapy, or combination external beam radiation/brachytherapy. Adjusted definitive treatment rates were calculated by rural–urban residence overall, and for different sociodemographic and cancer characteristics, and different states based on logistic regression analyses, using general estimating equation methods to account for clustering by county. RESULTS: Adjusted definitive treatment rates were lower for rural (83.7%) than urban (87.1%) patients with early-stage prostate cancer (P ≤ .01). Rural men were more likely than urban men to receive non-definitive surgical treatment and no initial treatment. The lowest definitive treatment rates were among rural subgroups: 70 to 74 years (73.9%), African Americans (75.6%), American Indians/Alaska Natives (77.8%), single/separated/divorced (76.8%), living in New Mexico (69.3%), and living in counties with persistent poverty (79.6%). CONCLUSIONS: Between 2004 and 2006, this adjusted analysis found that men who were living in rural areas were less likely to receive definitive treatment for their early-stage prostate cancer than those living in urban areas. Certain rural patient groups with prostate cancer need particular attention to ensure their access to appropriate treatment. Rural providers, rural health care systems, and cancer advocacy and support organizations should ensure resources are in place so that the most vulnerable rural groups (men between 60 and 74 years of age; African American men; men who are single, separated, or divorced; and men living in rural New Mexico) can make informed prostate cancer treatment choices based on their preferences. Access to Care Journal Article National Physicians RHRC access and evaluation health care quality prostatic neoplasms rural population SEER Program
Baldwin LM, Andrilla CHA, Porter MP, Rosenblatt RA, Patel S, Doescher MP	Do rural patients with early-stage prostate cancer gain access to all treatment choices?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2014	Full Report Policy Brief	Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?
Skillman SM, Patterson DG, Coulthard C, Mroz TM	Access to rural home health services: views from the field	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2016	Final Report	Access to Home Care Services in the Rural United States
Patterson DG, Schmitz D, Longenecker R, Andrilla CHA	Family medicine rural training track residencies: 2008-2015 graduate outcomes	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2016	Policy Brief	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Larson EH, Andrilla CHA, Morrison C, Ostergard SJ, Glicken A	Which physician assistant training programs produce rural PAs? A national study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2016	Policy Brief #154	Which Physician Assistant Training Programs Produce Rural Physician Assistants? A National Study
Skillman SM, Keppel GA, Patterson DG, Doescher MP	The contributions of community colleges to the education of allied health professionals in rural areas of the United States	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-31-2012	Full report	Community Colleges' Contributions to the Education of Allied Health Professionals in Rural Areas of the United States
Institute of Medicine	Community colleges and the education of allied health professionals in rural areas (summary of presentation by SM Skillman)	Institute of Medicine	02-10-2012		Community Colleges' Contributions to the Education of Allied Health Professionals in Rural Areas of the United States
Spetz J, Skillman SM, Andrilla CHA	Nurse practitioner autonomy and satisfaction in rural settings	Med Care Res Rev	01-29-2016	URL	Practice Characteristics of Rural Nurse Practitioners in the United States	Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice. CHWS Journal Article National News Nursing RHRC nurse practitioners nurses primary care rural health care scope of practice
Patterson DG, Keppel GA, Skillman SM, Berry C, Daniel C, Doescher MP	Recruitment of non-U.S. citizen physicians to rural and underserved areas through Conrad State 30 J-1 visa waiver programs	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-2015	Final Report	The Influence of State Policies and Practices on J-1 Visa Waiver Physicians' Service in Rural Areas
Skillman SM, Patterson DG, Andrilla CHA, Fenton S, Morrison C	Access to health information technology training programs at the community college level	Seattle. WA: WWAMI Rural Health Center, University of Washington	11-01-2015	Policy Brief	HIT Workforce Development in Rural-Serving Community Colleges
Doescher MP, Keppel GA	Dentist supply, dental care utilization, and oral health among rural and urban U.S. residents	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-2015	Full Report	Dentist Supply, Access to Dental Care, and Oral Health Among Rural and Urban Residents: A National Study
Allen SM, Ballweg RA, Cosgrove EM, Engle KA, Robinson LR, Rosenblatt RA, Skillman SM, Wenrich MD	Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI Program as a case study	Acad Med	11-27-2013	URL	WWAMI Physician Workforce Education	The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation’s most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals. The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents. Alaska CHWS Complete Idaho Journal Article Montana Physicians RHRC Washington Wyoming ACA accountable care organizations ACO graduate medical education health professionals medical education primary care physicians primary care workforce rural
Jackson JE, Doescher MP, Saver BG, Hart LG	Trends in professional advice to lose weight among obese adults, 1994-2000	J Gen Intern Med	01-01-2005	URL	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity	CONTEXT: Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. OBJECTIVE: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. DESIGN AND PARTICIPANTS: We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n = 10,705), 1996 (n = 13,800), 1998 (n = 18,816), and 2000 (n = 26,454) to examine changes in advice reported by obese adults seen for primary care. MEASUREMENTS: Self-reported advice from a health care professional to lose weight. RESULTS: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below 25,000 dollars, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (> 45%) over the study period. CONCLUSIONS: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity. Complete Health Care Outcomes and Quality Journal Article National RHRC obesity primary care professional advice weight loss
Jackson JE, Doescher MP, Jerant AF, Hart LG	A national study of obesity prevalence and trends by type of rural county	J Rural Health	01-01-2005	URL	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity	CONTEXT: Obesity is epidemic in the United States, but information on this trend by type of rural locale is limited. PURPOSE: To estimate the prevalence of and recent trends in obesity among US adults residing in rural locations. METHODS: Analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was obesity (body mass index [BMI] > or = 30), as determined by calculating BMI from respondents’ self-reported height and weight. RESULTS: In 2000-2001, the prevalence of obesity was 23.0% (95% confidence interval [CI] 22.6%-23.4%) for rural adults and 20.5% (95% CI 20.2%-20.7%) for their urban counterparts, representing increases of 4.8% (95% CI 4.2%-5.3%) and 5.5% (95% CI 5.1%-5.9%), respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties in Louisiana, Mississippi, and Texas; obesityprevalence increased for rural residents in all states but Florida over the study period. African Americans had the highest obesity prevalenceof any group, up to 31.4% (95% CI 29.1%-33.6) in rural counties adjacent to urban counties. The largest difference in obesity prevalencebetween those with a college education compared with those without a high school diploma occurred in urban areas (18.4% [95% CI 17.9%-18.9%] vs 23.5% [95% CI 22.5%-24.5%], respectively); the smallest difference occurred in small, remote rural counties (20.3% [95% CI 18.7%-21.9%] versus 22.3% [95% CI 20.7%-24.0%], respectively). CONCLUSIONS: The prevalence of obesity is higher in rural counties than in urban counties; obesity affects some residents of rural counties disproportionately. Complete Health Care Outcomes and Quality Journal Article National RHRC obesity rural urban
Jackson JE, Doescher MP, Jerant AF, Hart LG	Obesity prevalence in rural counties: a national study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2004	Full report Policy brief	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity
Doescher MP, Jackson JE, Jerant A, Hart LG	Prevalence and trends in smoking: a national rural study	J Rural Health	03-01-2006	URL	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking	CONTEXT: Cigarette smoking is the leading preventable cause of death in the United States. PURPOSE: To estimate the prevalence of and recent trends in smoking among adults by type of rural location and by state. METHODS: Random-digit telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was current cigarette smoking, defined as persons who smoke every day or some days, while nonsmokers were those who smoke not at all or reported never having smoked as many as 100 cigarettes. FINDINGS: The prevalence of smoking changed little from the mid-1990s; in 2000-2001, it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural nonadjacent areas, and 24.9% in small rural nonadjacent areas. For rural locations combined, smokingprevalence was not below the 12% goal of Healthy People 2010 for any state, although the 12.5% prevalence in rural Utah approached this target. Prevalence was > or = 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 percentage points in 6 states: California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2 percentage points or more in 10 states: 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. Complete Health Care Outcomes and Quality Journal Article National RHRC BRFSS prevalence public health rural Smoking
Jackson JE, Doescher MP, Jerant AF, Hart LG	Prevalence and trends in smoking: a national rural study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	12-31-2003	Full report Policy brief	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking
Jackson JE, Doescher MP, Hart LG	Problem drinking: rural and urban trends in America, 1995/1997 to 2003	Prev Med	08-01-2006	URL	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use	Objective. Studies examining trends in problem alcohol use for U.S. adults residing in rural locations are lacking. This study examines recent trends in heavy and binge drinking in urban counties and three types of rural counties. Methods. Random-digit telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System, in the years 1995/1997 (n = 247,255), 1999/2001 (n = 362,077) and 2003 (n = 257,659). Analyses were performed in 2006. Results. Metropolitan counties experienced higher prevalence of heavy and binge drinking than rural counties in all years, and all geographic areas showed upward trends in both drinking behaviors. Trends in heavy drinking were sharper in rural counties (3.8% to 5.4% compared with 4.9% to 6.0% in metro counties). Metropolitan and rural counties overall saw similar increases in binge drinking, however, the greatest increase occurred in remote micropolitan counties (12.7% to 15.7%). Conclusion. Heavy and binge drinking are problems that continue to increase in rural areas nationwide. Because of the difficulties inherent in accessing and administering substance abuse treatment in rural areas, special attention should be given to tailoring alcohol abuse interventions to the needs of rural residents. Complete Health Care Outcomes and Quality Journal Article National RHRC Alcohol abuse Binge drinking Heavy drinking rural health trends
Jackson JE, Doescher MP, Hart LG	Heavy and binge drinking in rural America: a comparison of rural and urban counties from 1995/1997 through 1999/2001	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2005	Full report	Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use
Baldwin LM, Grossman DC, Murowchick E, Larson EH, Hollow WB, Sugarman JR, Freeman WL, Hart LG	National trends in the perinatal and infant health of rural American Indians (AIs) and Alaska Natives (ANs): have the disparities between AI/ANs and whites narrowed?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-30-2008	Full report Policy brief	National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)
Baldwin LM, Grossman DC, Murowchick E, Larson EH, Hollow WB, Sugarman JR, Freeman WL, Hart LG	Trends in perinatal and infant health disparities between rural American Indians and Alaska Natives and rural whites	Am J Public Health	04-01-2009	URL	National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)	Objectives. We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time. Methods. We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births. Results. Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985–1987, 36.3%; 1995–1997, 26.3%) and postneonatal death (1985–1987, 7.1 per 1000; 1995–1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985–1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995–1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985–1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995–1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted. Conclusions. Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group. Previous studies and reports published by the Indian Health Service have demonstrated dramatic improvements in perinatal and infant health among American Indian and Alaska Native (AIAN) populations over the past 50 years. Infant mortality rates declined substantially from 62.7 per 1000 live births in 1955 to 9.3 per 1000 live births in the years 1994 to 1996.¹ Yet disparities between American Indians and Alaska Natives and Whites have persisted. In 1989–1991, American Indians and Alaska Natives overall had 2.4 times the rate of postneonatal death compared with the White population¹; rural American Indians and Alaska Natives had a postneonatal death rate 2.6 times that of Whites.² Since the mid-1980s, considerable attention has been paid to improving access to health care services, changing risk behaviors among pregnant women, and modifying provider practices, with the intention of improving birth outcomes and lowering infant mortality rates.^3–5 Among the general population, some of these efforts have been associated with higher rates of early and adequate prenatal care, as well as declining postneonatal mortality rates, especially from sudden infant death syndrome (SIDS).^6–8 However, it is not known how these efforts have influenced the perinatal health status of American Indians and Alaska Natives specifically, especially among rural American Indians and Alaska Natives, many of whom live in remote settings that may be more distant from health services. Our goal was to determine whether the disparities in perinatal care, birth outcomes, and infant health among rural American Indians and Alaska Natives and rural Whites diminished, remained stable, or increased during a period of policy, funding, and practice changes in maternal and child health care from the mid-1980s through the 1990s. We addressed these questions by examining trends in prenatal care receipt, low-birthweight rates, neonatal and postneonatal death rates, and causes of death among rural American Indians and Alaska Natives and Whites between 1985 and 1997. Complete Health Care Outcomes and Quality Journal Article National RHRC Alaska Native American Indian birth outcomes infant health perinatal care postneonatal death rural rural health care sudden infant death syndrome (SIDS)
Larson EH, Murowchick E, Hart LG	Poor birth outcome in the rural United States: 1985-1987 to 1995-1997	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-29-2008	Full report Policy brief	Changes in U.S. Rural Perinatal Care During the Last Decade
Andrilla CHA, Lishner DM, Hart LG	Rural dental practice: a tale of four states	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2006	Full report Policy brief	Rural Dentistry: Availability, Practice, and Access
Rosenblatt RA, Bovbjerg RR, Whelan A, Baldwin LM, Hart LG, Long C	Tort reform and the obstetric access crisis. The case of the WAMI states	West J Med	06-01-1991	URL	Tort Reform and the Obstetrical Access Crisis	The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetricservices during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians’ obstetricpractices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion. Comment in Tort reform works. [West J Med. 1991] Access to Care Alaska Complete Idaho Journal Article Montana Physicians RHRC Washington family physicians liability insurance Medicaid obstetric services Physicians tort reform
Rosenblatt RA, Whelan A, Hart LG, Long C, Baldwin LM, Bovbjerg RR	Tort reform and the obstetric access crisis: the case of the WAMI states	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-1990		Tort Reform and the Obstetrical Access Crisis
Skillman SM, Patterson DG, Lishner DM, Doescher MP, Andrilla CHA	The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #5: health workforce assessment: tools for policymakers and planners	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-27-2013	Policy brief	The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Skillman SM, Patterson DG, Lishner DM, Doescher MP, Fordyce MA	The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #4: what is rural in the WWAMI states? Why definitions matter	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-28-2013	Policy brief	The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Patterson DG, Lishner DM, Skillman SM, Doescher MP	The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #3: building and maintaining the rural health workforce: resources and strategies	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-29-2013	Policy brief	The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Patterson DG, Skillman SM, Andrilla CHA, Lishner DM, Doescher MP	The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #2: the rural health workforce in the WWAMI states: by the numbers	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-30-2013	Policy brief	The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Skillman SM, Patterson DG, Lishner DM, Doescher MP	The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #1: the rural health workforce: challenges and opportunities	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-31-2013	Policy brief	The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Doescher MP, Jackson JE, Fordyce MA, Lynge DC	Variability in general surgical procedures in rural and urban U.S. hospital inpatient settings	Seattle: WA, WWAMI Rural Health Research Center, University of Washington	02-01-2015	Full report	General and Specialist Surgeon Supply and Inpatient Procedural Content: A National Rural-Urban Study
Welch HG, Larson EH, Hart LG, Rosenblatt RA	Readmission after surgery in Washington State rural hospitals	Am J Public Health	03-01-1992	URL	Surgical Outcomes of Rural and Urban Hospitals	BACKGROUND. Because of concern about the quality of care in rural hospitals, we examined readmission following four surgical procedures commonly performed in Washington State rural hospitals: appendectomy, cesarean section, cholecystectomy, and transurethral prostatectomy. METHODS. In a retrospective cohort study, we identified all patients discharged after receiving one of the foregoing procedures using the statewide hospital discharge database. Readmissions to any hospital in the state within 7 or 30 days of discharge were also identified. RESULTS. During the 2-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals, although the readmission rates for all four procedures were nominally lower in rural hospitals. Logistic regression analyses that controlled for factors that influence readmission did not change these results. CONCLUSIONS. Investigating readmission rates following common surgeries, we found no evidence of low-quality surgical care in Washington State rural hospitals. Early readmission is an imperfect marker for poor surgical outcome, however, and other proxies for quality remain to be examined. Complete Health Care Outcomes and Quality Hospitals Journal Article Physicians RHRC Washington appendectomy cesarean section cholecystectomy rural hospitals rural vs urban surgery transurethral prostatectomy
Welch HG, Larson EH	Patients requiring at least five admissions in 1 year. Data from Washington State	Med Care	06-01-1991	URL	Surgical Outcomes of Rural and Urban Hospitals	Concern about rising health expenditures has fostered interest in patients who are frequent users of medical care, who were labeled “high utilizers” as early as 1959. Because of the high cost of inpatient services, subsequent research has generally focused on patients with frequent hospital admissions. Recent investigations have examined multiple admission in selected patient populations, including newborns, psychiatric patients, and Medicare beneficiaries. However, the characteristics of patients with multiple admissions have not been described among unselected populations. In this investigation, we report on multiple admissions among the general population of Washington state and focus on those patients requiring at least five admissions in 1 year. Complete Health Care Outcomes and Quality Hospitals Journal Article Physicians RHRC Washington hospital admissions hospitals multiple admissions
Welch HG, Larson EH, Hart LG, Rosenblatt RA	Readmission following surgery in Washington State rural hospitals	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-1991		Surgical Outcomes of Rural and Urban Hospitals
Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG	A longitudinal analysis of the general surgery workforce in the United States, 1981-2005	Arch Surg	04-01-2008	URL	Distribution and Retention of General Surgeons in Rural Areas of the U.S.	Hypothesis The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. Design Retrospective longitudinal analysis. Setting Clinically active general surgeons in the United States. Participants The American Medical Association’s Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. Main Outcome Measures Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. Results General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (−27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (−21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. Conclusions The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons. General surgeons play a pivotal role in the health care systems of the United States, particularly its rural areas.¹ They provide surgical backup to rural primary care physicians, ensure the success of rural trauma systems, and contribute to the financial viability of small rural hospitals.²^– 6 Urban general surgeons also provide important surgical services, including emergency and trauma care that some surgical subspecialists may not offer.⁷There is some question as to whether there will be an adequate number of general surgeons to care for an increasingly elderly population, with its attendant increased demand for surgical care.⁸ Recent studies⁹^– 11 have indicated that the overall number of general surgeons has remained static since 1994, despite an increase in population of 1% per annum during this period. This fact, coupled with the rise in surgical specialization, the decreased interest of medical students in general surgical careers, and the changes in demographics of medical students and surgery residents, has generated concern that there will soon be a shortage of general surgeons.¹²^– 16 Recent publications by the Institute of Medicine and the American College of Surgeons attest to staffing and availability problems of general, and other, surgeons for emergency services.¹⁷^,18 Our study group¹¹ found that the general surgeon to population ratio in the more remote rural areas of the United States was almost half that of urban areas. The present study builds on this previous work by adding a longitudinal dimension and describing the trends in the number, distribution, and characteristics of general surgeons in the United States during the 25 years from 1981 to 2005, with particular emphasis on surgeons in small and isolated rural areas. Examination of such trends is crucial to predicting and addressing future workforce problems. Access to Care Complete Journal Article National Physicians RHRC General surgeons rural rural primary care physicians
Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG	Characterizing the general surgery workforce in rural America	Arch Surg	01-01-2005	URL	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. HYPOTHESIS: We hypothesize that the rural areas of the United States are relatively undersupplied with general surgeons. DESIGN AND SETTING: The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their locations and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas. Surgeons were classified as practicing in urban areas, large rural areas, or small/isolated rural areas. RESULTS: There are currently 17 243 general surgeons practicing in the United States. Nationally, the number of general surgeons per population of 100 000 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 are female. Wide variations in numbers of general surgeons were found between and within individual states. General surgeons in the smallest rural areas are more likely than those in urban areas to be male (92.7% vs 88.3%, P<.001), 50 years of age or older (51.6% vs 42.1%, P<.001), or international medical graduates (25.2% vs 20.1%, P<.001). CONCLUSIONS: The overall size of the rural general surgical workforce has remained static over the last decade, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. Steps to reverse this trend are needed to preserve the viability of health care in many parts of rural America. Access to Care Complete Journal Article National Physicians RHRC General surgeons medical workforce rural urban
Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG	Characterizing the general surgery workforce in rural America	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-2004	Full report	Distribution and Retention of General Surgeons in Rural Areas of the U.S.
Larson EH, Johnson KE, Norris TE, Lishner DM, Rosenblatt RA, Hart LG	State of the health workforce in rural America: profiles and comparisons	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2003	Cover. Contents. Chapter 1. Chapter 2. Chapter 3. Chapter 4. Chapter 5. Chapter 6. References.	State Rural Health Workforce Monograph
Williamson HA, Rosenblatt RA, Hart LG	Physician staffing of small rural hospital emergency departments: rapid change and escalating cost	J Rural Health	06-01-1992	URL	Physician Staffing of Small Rural Hospital Emergency Departments	We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals. Access to Care Complete Hospitals Journal Article Physicians RHRC Washington emergency Physicians rural rural hospitals
Williamson H, Rosenblatt RA, Hart LG	Physician staffing of small rural hospital emergency departments: rapid change and escalating cost	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-01-1991		Physician Staffing of Small Rural Hospital Emergency Departments
Baldwin LM, Hollow WB, Casey S, Hart LG, Larson EH, Moore K, Lewis E, Andrilla CHA, Grossman DC	Access to specialty health care for rural American Indians in two states	J Rural Health	06-21-2008	URL	Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)	CONTEXT: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. PURPOSE: To examine specialty service access among rural Indian populations in two states. METHODS: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). FINDINGS: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service accessfor 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 both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. CONCLUSIONS: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients. Access to Care Complete Journal Article Physicians RHRC American Indian Indian Health Service (IHS) Montana New mexico rural specialty service
Baldwin LM, Hollow WB, Casey S	Access to specialty health care for rural American Indians: provider perceptions in two states	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-01-2004	Full report Policy brief	Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)
Larson EH, Hart LG, Rosenblatt RA	Rural residence and poor birth outcome in Washington State	J Rural Health	06-01-1992	URL	Quality of Obstetrical Care Provided to Rural Versus Urban Residents	It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome. Complete Health Care Outcomes and Quality Journal Article Physicians RHRC Washington birth outcomes hospitals rural rural vs urban
Larson EH, Hart LG, Rosenblatt RA	Is rural residence associated with poor birth outcome?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-1991		Quality of Obstetrical Care Provided to Rural Versus Urban Residents
Baldwin LM, Rosenblatt RA, Lishner DM, Hart LG, Schneeweiss R	Rural and urban physicians: does the content of their practices differ?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-1998		Who Are the Generalists in Rural and Urban Areas?
Baldwin LM, Rosenblatt RA, Schneeweiss R, Lishner DM, Hart LG	Rural and urban physicians: does the content of their Medicare practices differ?	J Rural Health	04-01-1999	URL	Who Are the Generalists in Rural and Urban Areas?	Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients. Access to Care Complete Journal Article Physicians RHRC Washington geographic location medical technology Medicare Physicians practice characteristics practices rural urban
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP	Inadequate prenatal care among racial and ethnic groups in the rural United States, 2005	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-12-2013	Policy brief	Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP	Inadequate prenatal care in the rural United States, 2005	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-13-2013	Policy brief	Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP	Low birth weight rates among racial and ethnic groups in the rural United States, 2005	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-14-2013	Policy brief	Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP	Low birth weight rates in the rural United States, 2005	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-15-2013	Policy brief	Perinatal Health in the Rural United States, 2005
Skillman SM, Palazzo L, Doescher MP, Butterfield P	Characteristics of rural RNs who live and work in different communities	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-28-2012	Full report Policy brief	Factors Associated with Rural-Residing Registered Nurses' Choices to work in Urban Locations and Larger Rural Cities
Rosenblatt RA, Andrilla CHA, Catlin M, Larson EH	Geographic and specialty distribution of US physicians trained to treat opioid use disorder	Ann Fam Med	01-01-2015	URL	The Supply of Physicians Waivered to Treat Opioid Addiction in Rural America: Policy Options to Remedy Critical Shortages	PURPOSE The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder—particularly in rural America—is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses. Access to Care In-Progress Journal Article National Physicians RHRC buprenorphine opiate addiction opiate substitution treatment opioid treatment programs primary health care rural health
Larson EH, Hart LG, Muus K, Geller J	Content of physician assistant practice: results from a national survey	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-1999	Full report	National Rural Physician Assistant Content of Care Study
Melzer SM, Grossman DC, Hart LG, Rosenblatt RA	Hospital services for rural children in Washington State	Pediatrics	02-01-1997	URL	Pediatric Inpatient Care in Rural Hospitals	Objective. To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family practitioners in the care of children in rural hospitals. Design. Retrospective review of statewide hospital discharge data. Subjects. All patients younger than 18 years of age with nonsurgical diagnoses discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990. Results. Of 69 690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners. Conclusions. Most rural children in Washington who require hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating rural practice receive training in general inpatient pediatrics (regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Because systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported. Access to Care Complete Journal Article Physicians RHRC Washington children hospital services hospitalization neonatal pediatricians pediatrics physician practice patterns referral patterns rural rural health
Melzer S, Grossman DC, Hart LG, Larson EH, Sodenberg R, Rosenblatt RA	Rural inpatient pediatrics: pediatricians and family physicians	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-01-1995		Pediatric Inpatient Care in Rural Hospitals
Skillman SM, Doescher MP, Mouradian WE, Brunson DK	The challenge to delivering oral health services in rural America	J Public Health Dent	06-01-2010	URL	Oral Health Services in Rural America	Objectives: 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. Methods: This descriptive article is based on literature reviews and personal communications. Results: Rural populations have lower dental care utilization, higher rates of dental caries, lower rates of insurance, higher rates of poverty, less water fluoridation, fewer dentists per population, and greater distances to travel to access care than urban populations. Improving the oral health of rural populations requires practical and flexible approaches to expand and better distribute the rural oral health workforce, including approaches tailored to remote areas. Solutions that involve mass prevention/public health interventions include increasing water fluoridation, providing timely oral health education, caries risk assessment and referral, preventive services, and offering behavioral interventions such as smoking and tobacco cessation programs. Solutions that train more providers prepared to work in rural areas include recruiting students from rural areas, training students in rural locations, and providing loan repayment and scholarships. Increasing the flexibility and capacity of the oral health workforce for rural areas could be achieved by creating new roles for and new types of providers. Solutions that overcome distance barriers include mobile clinics and telehealth technology. Conclusions: Rural areas need flexibility and resources to develop innovative solutions that meet their specific needs. Prevention needs to be at the front line of rural oral health care, with systematic approaches that cross health professions and health sectors. CHWS Complete Journal Article National Oral Health RHRC dental Education oral health Prevention rural solutions urban workforce
Rosenblatt RA, Dawson AJ, Larson EH, Tressler CJ, Jones A, Hart LG, Nesbitt TS	A comparison of the investment in hospital-based obstetrical ultrasound in Wales and Washington State	Int J Technol Assess Health Care	01-01-1995	URL	N/A	The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines–approximately two machines per 1,000 births–was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care. In-Progress Journal Article National Nursing RHRC Britain hospitals medical technology obstetrical ultrasound private pubnlic USA Wales Washington State
Hart LG, Taylor P	The emergence of federal rural health policy in the United States. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Larson EH, Hart LG	The rural physician. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Rosenblatt RA	The health of rural people and the communities and environments in which they work. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Wright GE	The economics of rural practice. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Norris TE	Telemedicine and telehealth service. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Geyman JP	Graduate education for rural practice. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Coombs JB	Quality of care in rural settings: Bringing the "new quality" to rural practice. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Coombs JB	Quality of care in rural settings: Bringing the "new quality" to rural practice. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Williams R, House P	Community oriented primary care and rural services development. In: Geyman JP, Norris TE, Hart LG, eds	Textbook of rural medicine	01-01-2001		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Rosenblatt RA, Hart LG	Chapter 3: Physicians and rural America. In: Ricketts TC, ed	Rural health in the United States	01-01-1999		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Lishner DM, Larson EH, Rosenblatt RA, Clark SJ	Chapter 12: Rural maternal and perinatal health. In: Ricketts TC, ed	Rural health in the United States	01-01-1999		FORHP Rural Health Research Center Book and Rural Medicine Textbook
Williamson HA Jr, Hart LG, Pirani MJ, Rosenblatt RA	Market shares for rural inpatient surgical services: where does the buck stop?	J Rural Health	04-01-1994	URL	Surgical Capacity of Rural Washington State Hospitals	Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals’surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals. In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state’s 42 rural hospitals. The Washington State Department of Health’s Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. “Total hospital expenses” from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense. For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons. Thirty-eight percent of hospitals had no general surgeon (classified as “minimal service” hospitals), 41 percent had at least one (“basic service” hospitals), and 21 percent had a comprehensive surgical staff consisting of general surgeons plus at least one anesthesiologist, gynecologist, orthopedist, and urologist (“comprehensive service” hospitals). Minimal service hospitals billed a mean of $90,000 annually for surgery; basic service hospitals, $1.5 million; and comprehensive service hospitals, $7.1 million. Billed surgical charges were 4 percent of total expenses at minimal service hospitals, 31 percent for basic service hospitals, and 41 percent for comprehensive service hospitals. There was a moderate amount of surgical activity at larger rural hospitals that represented rural-to-rural movement of surgical care, and this amounted to $14 million. More importantly, 60 percent of surgical charges billed on behalf of rural citizens ($116 million) went to urban hospitals. These data demonstrate the considerable potential financial advantage to hospitals that have surgical services. This financial advantage can in turn be used to support other important but less lucrative rural hospital services. If supporting some or all rural hospitals as they struggle financially is an important rural health goal, then public policy should be directed toward supporting appropriate surgical services at rural hospitals and encouraging the proper training and recruitment of rural surgeons. Access to Care Complete Health Care Outcomes and Quality Hospitals Journal Article Physicians RHRC Washington anesthesiologist General surgeons gynecologist orthopedist rural rural hospitals surgical services urologist
Williamson HA Jr, Hart LG, Pirani MJ, Rosenblatt RA	Rural hospital inpatient surgical volume: cutting-edge service or operating on the margin?	J Rural Health	11-01-1994	URL	Surgical Capacity of Rural Washington State Hospitals	Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington’s 42 rural hospitals. The Washington State Department of Health’s Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services–and these are considerable–but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens. Access to Care Complete Health Care Outcomes and Quality Hospitals Journal Article Physicians RHRC Washington rural rural hospitals surgeons surgical services
Williamson H, Hart LG, Pirani MJ, Rosenblatt RA	Market shares for rural surgical services: where does the buck stop?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1993		Surgical Capacity of Rural Washington State Hospitals
Williamson H, Hart LG, Pirani MJ, Rosenblatt RA	Rural hospital surgical volume: cutting edge service or operating on the margin?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-1993		Surgical Capacity of Rural Washington State Hospitals
Amundson BA, Hagopian A, Robertson DG	Implementing a community-based approach to strengthening rural health services: the Community Health Services Development Model (parts I and II)	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-1991		Transferability of the Rural Hospital Project
Hoare G, Katz A, Porter A, Dannenbaum A, Baldwin H	Rural hospital care linkages in the Northwest	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1991		Rural Hospital Linkages in the WAMI Region
Dyck SM, Hagopian A, House PJ, Hart LG	Northwest rural hospital governing boards	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-1997		Characteristics of Rural Hospital Governing Boards. Part C: Which Activities of Small Rural Hospital Boards Are Associated with Success?
Dyck SM, Hagopian A, House PJ, Hart LG	Northwest rural hospital governing boards	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-1997		Characteristics of Rural Hospital Governing Boards. Part B: An Assessment of the Knowledge of Governing Board Members in Rural Hospitals
Dyck SM, Hagopian A, House PJ, Hart LG	Northwest rural hospital governing boards	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-1997		Characteristics of Rural Hospital Governing Boards. Part A: Who Governs Rural Hospitals?
Lishner DM, Robertson DG, Rosenblatt RA, Hart LG	Educational and geographic career pathways of rural vs. urban hospital administrators	Hosp Health Serv Adm	09-01-1994	URL	Administrator Turnover in Rural Hospitals	Information on academic and geographic career patterns was obtained through a survey of 93 urban and rural hospital administrators in the State of Washington in 1990 (90 percent response rate). A greater proportion of urban than rural administrators had advanced degrees (93 versus 74 percent). While the most common career pathways were “always urban” (39 percent) and “always rural” (20 percent), there was little support for the presumption that hospital administrators use rural positions as stepping stones into urban careers. Complete Hospitals Journal Article Other/Multiple RHRC Washington degrees hospital administrators rural rural vs urban urban
Hart LG, Robertson DG, Lishner DM, Rosenblatt RA	CEO turnover in rural northwest hospitals	Hosp Health Serv Adm	09-01-1993	URL	Administrator Turnover in Rural Hospitals	This study examines rates of and reasons for turnover among administrators from 148 rural hospitals in four northwestern states. Data were obtained from a survey of CEOs who left their positions between 1987 and 1990 and from a survey of board members from those same hospitals. During the study period, 85 CEO turnovers occurred at 78 hospitals. High-turnover hospitals were generally smaller than those facilities with fewer turnovers. The annual rate of CEO turnover was 15 percent in 1988 and 16 percent in 1989. The reasons for turnover most often cited by those in their positions for less than four years were due to: seeking a better position elsewhere, an unstable health care system, conflict with hospital board members or with medical staff, and inadequate salary. High levels of self-reported job satisfaction and job performance by turnover CEOs contrasted to the much lower performance evaluations reported by hospital board members. Nearly three out of four board members indicated they would not rehire their departed CEOs. CEOs perceived their professional weaknesses to center on deficiencies in leadership and financial skills as well as problems with physician, hospital board, and community relations. Complete Hospitals Journal Article Other/Multiple RHRC Washington CEOs rural hospitals turnovers
Hart LG, Robertson DG, Lishner DM, Rosenblatt RA	CEO turnover in rural WAMI hospitals	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-1992		Administrator Turnover in Rural Hospitals
Baldwin LM, Chan L, Andrilla CHA, Huff E, Hart LG	Quality of care for acute myocardial infarction: are the gaps between rural and urban hospitals closing?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2010	Full report Policy brief	Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?
Baldwin LM, Chan L, Andrilla CHA, Huff ED, Hart LG	Quality of care for myocardial infarction in rural and urban hospitals	J Rural Health	02-01-2010	URL	Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?	Background: In the mid-1990s, significant gaps existed in the quality of acute myocardial infarction (AMI) care between rural and urban hospitals. Since then, overall AMI care quality has improved. This study uses more recent data to determine whether rural-urban AMI quality gaps have persisted. Methods: Using inpatient records data for 34,776 Medicare beneficiaries with AMI from 2000-2001, unadjusted and logistic regression analysis compared receipt of 5 recommended treatments between admissions to urban, large rural, small rural, and isolated small rural hospitals as defined by Rural Urban Commuting Area codes. Results: Substantial proportions of hospital admissions in all areas did not receive guideline-recommended treatments (eg, 17.0% to 23.6% without aspirin within 24 hours of admission, 30.8% to 46.6% without beta-blockers at arrival/discharge). Admissions to small rural and isolated small rural hospitals were least likely to receive most treatments (eg, 69.2% urban, 68.3% large rural, 59.9% small rural, 53.4% isolated small rural received discharge beta-blocker prescriptions). Adjusted analyses found no treatment differences between admissions to large rural and urban area hospitals, but admissions to small rural and isolated small rural hospitals had lower rates of discharge prescriptions such as aspirin and beta-blockers than urban hospital admissions. Conclusions: Many simple guidelines that improve AMI outcomes are inadequately implemented, regardless of geographic location. In small rural and isolated small rural hospitals, addressing barriers to prescription of beneficial discharge medications is particularly important. The best quality improvement practices should be identified and translated to the broadest range of institutions and providers. Complete Health Care Outcomes and Quality Hospitals Journal Article National RHRC acute myocardial infarction Medicare myocardial infarction quality of care rural rural hospital rural hospitals urban
Dunbar PJ, Mayer JD, Fordyce MA	Availability of anesthesia personnel in rural Washington and Montana	Anesthesiology	03-01-1998	URL	The Provision of Anesthesia Services in Rural Hospitals	anesthesiology hospitals nonsurgical rural surgical workforce
Dunbar P, Mayer JD, Fordyce MA	A profile of anesthesia provision in rural Washington and Montana	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-1996		The Provision of Anesthesia Services in Rural Hospitals
Skillman SM, Andrilla CHA, Patterson DG, Fenton SH, Ostergard SJ	Health information technology workforce needs of rural primary care practices	J Rural Health	05-08-2014	URL	Health Information Technology (HIT) Workforce Needs in Rural America	PURPOSE: This study assessed electronic health record (EHR) and health information technology (HIT) workforce resources needed by ruralprimary care practices, and their workforce-related barriers to implementing and using EHRs and HIT. METHODS: Rural primary care practices (1,772) in 13 states (34.2% response) were surveyed in 2012 using mailed and Web-based questionnaires. FINDINGS: EHRs or HIT were used by 70% of respondents. Among practices using or intending to use the technology, most did not plan to hire new employees to obtain EHR/HIT skills and even fewer planned to hire consultants or vendors to fill gaps. Many practices had staff with some basic/entry, intermediate and/or advanced-level skills, but nearly two-thirds (61.4%) needed more staff training. Affordable access to vendors/consultants who understand their needs and availability of community college and baccalaureate-level training were the workforce-related barriers cited by the highest percentages of respondents. Accessing the Web/Internet challenged nearly a quarter of practices in isolated rural areas, and nearly a fifth in small rural areas. Finding relevant vendors/consultants and qualified staff were greater barriers in small and isolated rural areas than in large rural areas. DISCUSSION/CONCLUSIONS: Rural primary care practices mainly will rely on existing staff for continued implementation and use of EHR/HIT systems. Infrastructure and workforce-related barriers remain and must be overcome before practices can fully manage patient populations and exchange patient information among care system partners. Efforts to monitor adoption of these skills and ongoing support for continuing education will likely benefit rural populations. Complete Journal Article National Other/Multiple RHRC electronic health records primary care technology workforce
Doescher MP, Keppel GA, Skillman SM	Policy brief: the crisis in rural dentistry	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-2009	Policy brief	Health Care Reform Policy Briefs on Rural Health Workforce Issues
Doescher MP, Skillman SM, Rosenblatt RA	Policy brief: the crisis in rural primary care	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-02-2009	Policy brief	Health Care Reform Policy Briefs on Rural Health Workforce Issues
Doescher MP, Lynge DC, Skillman SM	Policy brief: the crisis in rural general surgery	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-04-2009	Policy brief	Health Care Reform Policy Briefs on Rural Health Workforce Issues
Skillman SM, Doescher MP, Rosenblatt RA	Policy brief: threats to the future supply of rural registered nurses	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-03-2009	Policy brief	Health Care Reform Policy Briefs on Rural Health Workforce Issues
House PJ	State-based evaluations of the Flex Program	CAH/Flex National Tracking Project: Findings from the Field	01-01-2003		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Johnson KE, Fordyce MA, Blades S, Hart LG	Staffing the business office in critical access hospitals while meeting regulatory and payment system challenges	CAH/Flex National Tracking Project: Findings from the Field	01-01-2003		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Johnson KE, Fordyce MA, Blades S, Hart LG	Health workforce recruitment and retention in critical access hospitals	CAH/Flex National Tracking Project: Findings from the Field	01-01-2003		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Thompson MJ, Kaltenbach E, Hart LG	The role of international medical graduates in America's small rural "critical access" hospitals	CAH/Flex National Tracking Project: Findings from the Field	01-01-2003		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG	Administration in critical access hospitals	CAH/Flex National Tracking Project: Findings from the Field	01-01-2001		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG	Critical access hospitals and community development	CAH/Flex National Tracking Project: Findings from the Field	01-01-2001		National Rural Hospital Flexibility Program Tracking Project
Hagopian A	The CAH start-up kit	CAH/Flex National Tracking Project: Findings from the Field	01-01-2000		National Rural Hospital Flexibility Program Tracking Project
Hagopian A	Modeling economic changes in communities and their health systems	CAH/Flex National Tracking Project: Findings from the Field	01-01-2000		National Rural Hospital Flexibility Program Tracking Project
Flex/CAH Tracking Team	Rural Hospital Flexibility Program: the tracking project third-year findings	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2002		National Rural Hospital Flexibility Program Tracking Project
Flex/CAH Tracking Team	The Rural Hospital Flexibility Program, the Tracking Project: second-year findings	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2001		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG, Poley S, Flex/CAH Tracking Team	Rural Hospital Flexibility Program: The Tracking Project first-year findings	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2000		National Rural Hospital Flexibility Program Tracking Project
	Rural Hospital Flexibility Program Tracking Project Year 02 report	WWAMI Rural Health Research Center and five collaborating centers	01-01-2001		National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG	Rural Hospital Flexibility Program: The tracking project reports first-year findings	J Rural Health	04-01-2001	URL	National Rural Hospital Flexibility Program Tracking Project	TOPIC EDITORS NOTE: The Balanced Budget Act (BBA) of 1997 set in motion changes in how health care services are financed and organized. Legislation in 1999 and 2000 modifying the BBA confirmed a congressional sense that innovations in payment might precipitate changes in the delivery systems that could sustain those systems in rural areas. It is too early to judge whether or not new approaches, suck as critical access hospitals, will strengthen the financial viability of rural systems while sustaining and improving quality of care. However, this report from the research centers tracking responses to the legislation does tell us how hospitals and state governments are responding to new opportunities. From that knowledge, we gain a sense of whether or not the new model is workable, a prerequisite to its being successful. As we approach the final two years of the original authorization for the grant program, a careful assessment of what we have learned will inform decisions about further investments in the rural health care delivery infrastructure. -Keith J Mueller, Ph.D., Health Policy Topic Editor Access to Care Complete Hospitals Journal Article National RHRC critical access hospitals (CAH) Flex Program hospitals rural rural health Rural Hospital Flexibility Program
Hart LG, Lishner DM, Larson EH	Pathways to rural practice: a chartbook of family medicine residency training locations and characteristics	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2005	Cover. Introduction. Chapter 1. Chapter 2. Chapter 3. Chapter 4. Chapter 5. References.	Chartbook of Family Practice Graduate Medical Education Programs in Rural America
Chen FM, Andrilla CHA, Doescher MP, Morris C	Family medicine residency training in rural locations	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	07-01-2010	Full report Policy brief	Rural Family Medicine Residency Training Follow-Up Survey Regarding Amount and Types of Rural Training Experiences
Patterson DG, Skillman SM, Fordyce MA	Prehospital emergency medical services personnel in rural areas: results from a survey in nine states	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-03-2015	Final Report	The Pre-hospital Emergency Medical Services Workforce in Rural and Urban Areas
Grossman DC, Hart LG, Rivara FP, Maier RV, Rosenblatt RA	From roadside to bedside: the regionalization of trauma care in a remote rural county	J Trauma	01-01-1995	URL	Regionalization of Rural Emergency Medical Services (EMS)	Objective To determine the current role of rural hospitals and prehospital agencies in the care of motor vehicle crash victims in a remote, rural county prior to the statewide regionalization of trauma care. Specifically, we determined the proportion of crashes that required a response by emergency medical services (EMSs), the timeliness of the response, the proportion of patients treated in local hospitals, and the factors that predicted referral to trauma centers. Design Population-based retrospective cohort study linking emergency medical services, emergency department, and hospital discharge data to police motor vehicle crash reports and coroner data. Setting Okanogan County, Washington. Subjects All motor vehicle occupants, pedestrians or pedal-cyclists who were involved in a motor vehicle collision with a response by emergency medical system personnel or the county coroner. Intervention None. Main Outcome Measures EMS response times, emergency department and hospital discharge disposition, Injury Severity Scores, hospital length of stay, procedures, deaths. Results Twelve percent of 669 crashes reported to the police led to the dispatch of EMS. Crashes with EMS involvement were more likely to include occupants without restraints, who were ejected from the vehicle or who had alcohol as a contributing circumstance. The median interval between crash and EMS dispatch was 5 minutes (95th percentile: 40 minutes), the median scene time was 15 minutes (95th percentile: 35 minutes), and the median interval between dispatch and emergency department arrival was 48 minutes (95th percentile: 95 minutes). Among the 210 patients treated by EMSs, 67 (32%) were admitted to local hospitals, and 19 (9%) were referred to a distant trauma center. Of these, 17 were referred directly from the emergency department, one from the scene, and one after local admission. Compared with patients who were admitted locally, referred patients had a significantly higher mean Injury Severity Score (14.4 vs. 5.1), hospital length of stay (9.1 vs. 1.8 days), and rate of operative procedures (37% vs. 9%). Of the 13 crash-related deaths during the year, nine were declared dead at the scene before EMS arrival, three were asystolic at the time of EMS arrival at the scene, and one died at a referral hospital. Conclusions The linkage of data from police, prehospital agencies, and hospitals can reveal important information about the sequence of health care for trauma patients. The rural hospitals in this county currently play a major role in the stabilization and treatment of motor vehicle crash victims. Access to Care Complete Health Care Outcomes and Quality Hospitals Journal Article RHRC Washington Emergency Medical Services EMS motor vehicle crash Okanogan County rural rural hospitals
Hart LG, Larson EH, Lishner DM	Rural definitions for health policy and research	Am J Public Health	07-01-2005	URL	Description of Differences Between Seclected Rural-Urban Taxonomies	The term “rural” suggests many things to many people, such as agricultural landscapes, isolation, small towns, and low population density.However, defining “rural” for health policy and research purposes requires researchers and policy analysts to specify which aspects of rurality are most relevant to the topic at hand and then select an appropriate definition. Rural and urban taxonomies often do not discuss important demographic, cultural, and economic differences across rural places-differences that have major implications for policy and research. Factors such as geographic scale and region also must be considered. Several useful rural taxonomies are discussed and compared in this article. Careful attention to the definition of “rural” is required for effectively targeting policy and research aimed at improving the health of rural Americans. Complete Journal Article Methods RHRC rural rural definition rural taxonomy urban
Morrill R, Cromartie J, Hart LG	Metropolitan, urban, and rural commuting areas: toward a better depiction of the U.S. settlement system	Urban Geog	01-01-1999	URL	Rural Definition Reclassification Project
Morrill R, Cromartie J, Hart LG	Metropolitan, urban, and rural commuting areas: toward a better depiction of the U.S. settlement system	Urban Geog	01-01-1999	URL	Rural Definition Reclassification Project
Wright GE, Andrilla CHA, Hart LG	How many physicians can a rural community support? A practice income potential model for Washington State	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-2001	Full report	How Many Physicians Can a Rural Town Support?
Norris TE, Reese JW, Pirani MJ, Rosenblatt RA	Are rural family physicians comfortable performing cesarean sections?	J Fam Pract	11-01-1996	URL	Rural C-Sections and Family Physicians	BACKGROUND: Provision of obstetric care in the United States requires the capacity to perform cesarean sections. It is unknown who actually performs these procedures in rural hospitals and whether nonobstetricians feel comfortable performing cesarean sections. METHODS: We conducted a telephone survey of the 41 rural hospitals in Washington State, asking about the obstetric services offered and the composition and obstetrical practices of physician staff. A supplementary questionnaire was sent to the 112 family physicians providing obstetric services in the subset of hospitals with 50 or fewer beds, asking whether they performed cesarean sections. Eighty-six responded, for a response rate of 75%. RESULTS: Thirty-one (75%) of the rural hospitals provide obstetric services; of the 31 hospitals, 19 (61%) had no obstetricians on staff. In these hospitals the majority of physicians on staff both practice obstetrics and perform cesarean sections. Family physicians performed the majority of cesarean sections in all but the eight largest rural hospitals; even in these large hospitals (mean annual deliveries, 785), family physicians performed 28% of the cesarean sections. Most family physicians who performed cesarean sections felt very comfortable performing these operations. There was a strong association between the number of cesarean sections performed in formal residency training settings and the family physician’s comfort level. CONCLUSIONS: Cesarean sections remain an important service in those rural hospitals providing obstetric services. Most Washington State rural hospitals depend on family physicians for this operative intervention. Physicians’ comfort in doing cesarean sections appears to be closely related to prior formal training during residency. This relationship suggests that training programs preparing future rural physicians need to ensure adequate training in this area for their residents. Access to Care Journal Article Physicians RHRC Washington caesarean family physicians obstetric care rural rural hospitals
Norris TE, Reese JW, Rosenblatt RA	Are rural family physicians comfortable performing cesarean sections?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-1996		Rural C-Sections and Family Physicians
Patterson DG, Schmitz D, Longenecker R, Squire D, Skillman SM	Graduate medical education financing: sustaining medical education in rural places	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-26-2015	Policy brief	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Phillips RL Jr, Skillman SM, Doescher MP	Policy brief: rural residency training for family medicine physicians: graduate early-career outcomes, 2008-2012	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-28-2013	Policy brief	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Xierali IM, Phillips Jr RL, Skillman SM, Doescher MP	Policy brief: rural residency training for family medicine physicians: graduate early-career outcomes	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-27-2012	Policy brief	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Skillman SM, Doescher MP	Policy brief: training physicians for rural practice: capitalizing on local expertise to strengthen rural primary care	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-19-2011	Policy brief	Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Cullen TJ, Hart LG, Whitcomb ME, Rosenblatt RA	The National Health Service Corps: rural physician service and retention	J Am Board Fam Pract	07-01-1997	URL	National Health Service Corps Scholarship Recipient Retention Study	BACKGROUND: The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas. METHODS: The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention. RESULTS: Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees. CONCLUSIONS: Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still ruralpractitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment. Complete Journal Article Methods National Physicians RHRC medically underserved areas National Health Service Corps (NHSC) Physicians retention rural
Cullen TJ, Hart LG, Whitcomb ME, Lishner DM, Rosenblatt RA	The National Health Service Corps: rural physician service and retention	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-01-1994		National Health Service Corps Scholarship Recipient Retention Study
Ellsbury KE, Baldwin LM, Johnson KE, Runyan S, Hart LG	Gender-related factors in the recruitment of generalist physicians to the rural Northwest	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2001	Full report Policy brief	Best Strategies for Recruiting Women Physicians to Rural Practice
Ellsbury KE, Baldwin LM, Johnson KE, Runyan SJ, Hart LG	Gender-related factors in the recruitment of physicians to the rural Northwest	J Am Board Fam Pract	09-01-2002	URL	Best Strategies for Recruiting Women Physicians to Rural Practice	Background: This study examines differences in the factors female and male physicians considered influential in their rural practice location choice and describes the practice arrangements that successfully recruited female physicians to rural areas. Methods: This cross-sectional study was based on a mailed survey of physicians successfully recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Results: Responses from 77 men and 37 women (response rate 61%) indicated that women were more likely than men to have been influenced in making their practice choice by issues related to spouse or personal partner, flexible scheduling, family leave, availability of childcare, and the interpersonal aspects of recruitment. Commonly reported themes reflected the respondents’ desire for flexibility regarding family issues and the value they placed on honesty during recruitment. Conclusions: It is very important in recruitment of both men and women to highlight the positive aspects of the community and to involve and assist the physician’s spouse or partner. If they want to achieve a gender-balanced physician workforce, rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse-partner, and interpersonal issues in the recruitment process. Access to Care Complete Journal Article National Physicians RHRC gender Physicians practice choices recruitment rural workforce
Baldwin LM, Patel S, Andrilla CHA, Rosenblatt RA, Doescher MP	Receipt of recommended radiation therapy among rural and urban cancer patients	Cancer	10-09-2012	URL Announcement	Use of Recommended Radiation Therapy in the Rural U.S.	BACKGROUND: Rural populations have limited geographic access to radiation therapy. The current study examines whether rural patients with cancer are less likely than urban patients with cancer to receive recommended radiation therapy, and identifies factors influencing rural versus urban differences in radiation therapy receipt. METHODS: The current study included 14,692 rural and 107,834 urban patients with 5 cancer types and stages for which radiation therapy was recommended. The authors used 2000 to 2004 Surveillance, Epidemiology, and End Results (SEER) Limited-Use Data from 8 state-based (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Mexico, and Utah) and 3 county-based (Atlanta, rural Georgia, and Seattle/Puget Sound) cancer registries. Adjusted radiation therapy receipt rates were calculated by rural versus urban residence overall, for different sociodemographic and cancer characteristics, and for different states based on logistic regression analyses using general estimating equation methods to account for patient clustering by county. RESULTS: Adjusted rates of radiation therapy receipt were lower for rural (62.1%) than urban (69.1%) patients with breast cancer (P ≤ .001). Among patients with breast cancer, radiation therapy receipt differed more by sociodemographic characteristics (eg, rural patients aged < 50 years had a 67.1% receipt rate, whereas those aged ≥ 80 years had a radiation therapy receipt rate of 29.1%) than rural versus urban residence. Adjusted rates of radiation therapy receipt were similar for rural and urban patients with other cancer types overall (66.1% vs 68.2%; difference not significant), although there were differences between urban and rural patients with regard to radiation therapy receipt for patients with stage IIIA nonsmall cell lung cancer (66.2% vs 60.7%; P ≤ .01). CONCLUSIONS: Sociodemographics, cancer types and stages, and state of residence appear to have a greater influence over receipt of radiation therapy than rural versus urban residence location, suggesting that factors such as social support, receipt of other cancer treatments, and regional practice patterns are important determinants of radiation therapy receipt. Access to Care Complete Journal Article National Physicians RHRC lung cancer radiation therapy regional practice rural rural vs urban SEER
Larson EH, Hart LG, Rosenblatt RA	Is non-metropolitan residence a risk factor for poor birth outcome in the U.S.?	Soc Sci Med	07-01-1997	URL	The Process and Quality of Rural Perinatal Care: A National Study	The association between nondashmetropolitan residence and the risk of poor birth outcome in the United States was examined using the records of 11.06 million singleton births in the United States between 1985 and 1987. Rates of neonatal and post-neonatal death, low birth weight and late prenatal care among nondashmetropolitan residents were compared to the rates among metropolitan residents. The association between residence in a nondashmetropolitan area and the risk of poor birth outcome was assessed in national and state level regression analyses. Residence in a nondashmetropolitan county was not found to be associated with increased risk of low birth weight or neonatal mortality at the national level or in most states, after controlling for several demographic and biological risk factors. Nondashmetropolitan residence was associated with greater risk of post-neonatal mortality at the national level. Nondashmetropolitan residence was strongly associated with late initiation of prenatal care at both the national level and in a majority of the states. Residence in nondashmetropolitan areas does not appear to be associated with higher risk of adverse birth outcome. Regionalization of perinatal care and other changes in the rural health care system may have mitigated the risk associated with residing in areas relatively isolated from tertiary care. High levels of late prenatal care among nondashmetropolitan residents suggest a continuing problem of access to routine care for rural women and their infants that may be associated with higher levels of post-neonatal mortality and childhood morbidity. Access to Care Complete Health Care Outcomes and Quality Journal Article National RHRC infant mortality low birth weight prenatal care rural health
Larson EH, Hart LG, Rosenblatt RA	Is rural residence a risk factor for poor birth outcomes? A national study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	12-01-1995		The Process and Quality of Rural Perinatal Care: A National Study
Chen FM, Fordyce MA, Andes S, Hart LG	Which medical schools produce rural physicians? A 15-year update	Acad Med	04-01-2010	URL	Which Training Programs Produce Rural Physicians? A National Health Workforce Study	PURPOSE: Despite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States. METHOD: Using a national cross-sectional analysis of the 2005 American Medical Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of clinically active MD and DO physicians who graduated from medicalschool between 1988 and 1997. RESULTS: Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in 2005. Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural areas. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. Rural residency trainees were over three times more likely to practice in rural areas (RR = 3.4, P < .001). CONCLUSIONS: The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend worsening shortages of rural physicians. Complete Journal Article National Physicians RHRC DO MD Physicians primary care rural rural practice urban
Chen FM, Fordyce MA, Andes S, Hart LG	U.S. rural physician workforce: analysis of medical school graduates from 1988-1997	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-01-2008	Full report Policy Brief	Which Training Programs Produce Rural Physicians? A National Health Workforce Study
Geyman JP, Hart LG	Primary care at a crossroads: progress, problems, and future projections	J Am Board Fam Pract	02-01-1994	URL	Primary Care at a Crossroads Project	The tension between generalist and specialist roles in medical education and practice has been marked by recurrent perceived crises for many years in the United States. Primary care was at a crossroads during the 1960s. There was much turmoil within the health care system, and many in the population were unable to gain access to and afford health care. As a result of this turbulence, a major effort was mounted at state and federal levels to increase the proportion and number of primary care physicians. New initiatives included efforts to increase the total number of physicians, passage of Medicare and Medicaid legislation, new emphasis on education programs in primary care, recognition of family practice as a specialty, and emergence of the National Health Service Corps. Today, 25 years later, the health care system as a whole is unraveling and in crisis as a result of soaring costs, the difficulty of providing access to all citizens, and health care outcomes that have fallen short of those achieved in many other industrialized countries. It is ironic how many of the failings of today’s health care system mirror those of the 1960s, and how parallel the approaches to address these problems are to those taken a generation ago. Primary care finds itself again at a crossroads as intense pressures mount for fundamental reform of a health care system that has an inadequate primary care base. It is timely to take stock of the progress achieved by the initiatives to expand primary care during the last 25 years. Accordingly, this report addresses the following four objectives: (1) to summarize the results of the initiatives of the 1960s in terms of changes in medical education, the evolving status of primary care, and both specialty and geographic distribution of physicians; (2) to discuss some of the factors affecting the decline of primary care; (3) to consider briefly the problems resulting from a health care system that does not have an adequate generalist base; and (4) to discuss the implications of the current situation with discussion of future projections for primary care. Complete Journal Article National Physicians RHRC generalist medical education Physicians practice primary care specialist
Geyman JP, Hart LG	Primary care at a crossroads: progress, problems and policy options	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-1993		Primary Care at a Crossroads Project
Ellsbury KE, Doescher MP, Hart LG	U.S. medical schools and the rural family physician gender gap	Fam Med	05-01-2000	URL	The Rural/Urban Practice Location Patterns of Women Medical School Graduates	BACKGROUND: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice. METHODS: This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medicalschools most successful at producing rural family physicians and general practitioners of both genders. RESULTS: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school’s 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts. CONCLUSIONS: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice. Comment in Successful Duluth program narrows the gender gap. [Fam Med. 2001] Access to Care Complete Journal Article National Physicians RHRC family physicians gender general practitioners generalist Physicians rural workforce
Ellsbury KE, Doescher MP, Hart LG	U.S. medical schools and the rural family physician gender gap	Fam Med	05-01-2000	URL	The Rural/Urban Practice Location Patterns of Women Medical School Graduates	BACKGROUND: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice. METHODS: This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medicalschools most successful at producing rural family physicians and general practitioners of both genders. RESULTS: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school’s 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts. CONCLUSIONS: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice. Comment in Successful Duluth program narrows the gender gap. [Fam Med. 2001] Access to Care Complete Journal Article National Physicians RHRC family physicians gender general practitioners generalist Physicians rural workforce
Doescher MP, Ellsbury KE, Hart LG	The distribution of rural female generalist physicians in the United States	J Rural Health	04-01-2000	URL	The Rural/Urban Practice Location Patterns of Women Medical School Graduates	Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care. Access to Care Complete Journal Article National Physicians RHRC female allopathic physicians female generalist physicians gender rural
Ellsbury KE, Doescher MP, Hart LG	The production of rural female generalists by U.S. medical schools	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-1999	Full report Policy brief	The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Doescher MP, Ellsbury KE, Hart LG	The distribution of rural female physicians in the United States	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-1998		The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Schleuning D, Rice G, Rosenblatt RA	Addressing barriers to perinatal care: a case study of the Access to Maternity Care Committee in Washington State	Public Health Rep	01-01-1991	URL	Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)	Access to obstetrical services has deteriorated in recent years, as large numbers of physicians have discontinued or restricted obstetrical practice. In Washington State, one response to this access crisis has been the establishment of the Access to Maternity Care Committee (AMCC), an ad hoc group composed primarily of private sector obstetrical providers and representatives of State government responsible for the delivery of health care to women and children. The major objective of the AMCC is to improve access to obstetrical services for socially vulnerable women, both rural inhabitants and the medically indigent. The committee has been successful in serving as a forum in which to resolve many of the administrative problems that have arisen between private sector obstetrical providers and the State’s Medicaid Program, the major source of payment for the one-third of pregnant women who are medically indigent. Building upon the trust that the committee members developed in working together, the AMCC served as a major force in persuading the State legislature to expand substantially its investment in perinatal care by increasing Medicaid eligibility, raising provider reimbursement, and improving social services for pregnant women. Such ad hoc coalitions between the private and public sector may be quite effective in addressing obstetrical access problems in other States. Complete Journal Article Physicians RHRC Washington Medicaid medically indigent obstetrical services perinatal care Physicians reimbursement rural social services
Schleuning D, Rice G, Rosenblatt RA	Addressing barriers to rural perinatal care: a case study of the access to maternity care committee in Washington State	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-01-1989		Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)
Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CHA, Chen FM	Family medicine training in rural areas	JAMA	09-04-2002	URL	Physician Residency Rural Training Baseline Study	To the Editor: The discipline of family medicine was created in the 1970s, in part, as a way to address the chronic shortage of US rural physicians.¹ It was predicted that the new discipline would augment the supply of rural clinicians because family physicians are much more likely than other physicians to settle in rural areas.² There is also empirical evidence that training family physicians in rural areas increases the likelihood that residency graduates will choose to settle in rural places.³^– 6 However, the exact proportion of family medicine residency programs located in truly rural parts of the United States remains unknown, as does the extent to which training rural physicians is a priority of existing family medicine residency programs. Access to Care Complete Journal Article National Physicians RHRC family medicine residency family physicians rural
Schneeweiss R, Rosenblatt RA, Dovey S	The effects of the 1997 Balanced Budget Act on family practice residency training programs	Fam Med	02-01-2003	URL	Physician Residency Rural Training Baseline Study	BACKGROUND AND OBJECTIVES: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residencytraining programs in the United States. METHODS: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. RESULTS: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997to 4.8 per year in the 4 years following passage of the BBA. CONCLUSIONS: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue. Access to Care Complete Journal Article National Physicians RHRC family practice residency graduate medical education Primary care physician rural physicians teaching hospitals urban underserved
Chen FM, Phillips RL Jr, Schneeweiss R	Accounting for graduate medical education funding in family practice training	Fam Med	10-01-2002	URL	Physician Residency Rural Training Baseline Study	BACKGROUND AND OBJECTIVES: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding. METHODS: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs’ knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. RESULTS: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME fundingthey received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%). CONCLUSIONS: More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education. Access to Care Complete Journal Article National Physicians RHRC family practice residency federal funding graduate medical education hospitals Medicare
Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CHA, Chen FM	Family medicine residency training in rural areas: how much is taking place, and is it enough to prepare a future generation of rural family physicians?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2002	Full report	Physician Residency Rural Training Baseline Study
Chan L, Hart LG, Goodman DC	Geographic access to health care for rural Medicare beneficiaries	J Rural Health	03-01-2006	URL	Access to Physician Care for the Rural Medicare Elderly	CONTEXT: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. PURPOSE: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington. METHODS: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient’s and the provider’s zone improvement plan codes. FINDINGS: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Ruralresidents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists. CONCLUSIONS: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care. Alaska Complete Idaho Journal Article Physicians RHRC Washington Alaska distance Idaho Medicare North Carolina rural South Carolina travel time Washington
Chan L, Hart LG, Goodman DC	Geographic access to health care for rural Medicare beneficiaries	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-2005	Full report	Access to Physician Care for the Rural Medicare Elderly
Rosenblatt RA, Saunders GR, Tressler CJ, Larson EH, Nesbitt TS, Hart LG	The diffusion of obstetric technology into rural U.S. hospitals	Int J Technol Assess Health Care	06-01-1994	URL	Diffusion of New Perinatal Technology into Rural Areas of Washington State	We determined the distribution and sophistication of obstetric technologies in all 80 maternity hospitals in the state of Washington and examined the effect of rural or urban location, birth volume, and physician staffing on technological intensity. Although smaller and more rural hospitals refer most premature and low-birth-weight infants to regional referral centers, sophisticated prenatal and intrapartum technologies are available in the majority of even the smallest and most remote rural units. Rural hospitals have slightly lower obstetrical intervention rates than do their urban counterparts, but the differences are not great. Access to Care Complete Hospitals Journal Article RHRC Washington obstetric technologies physician rural rural hospitals rural vs urban urban
Rosenblatt RA, Saunders G, Tressler C, Larson EH, Nesbitt TS, Hart LG	Do rural hospitals have less obstetric technology than their urban counterparts? A statewide study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-1993		Diffusion of New Perinatal Technology into Rural Areas of Washington State
Whelan AR	Geographical aspects of obstetrical care in Washington State	Master of Arts thesis. Seattle, WA: University of Washington	01-01-1989		Obstetrical Access in Washington State
Rosenblatt RA, Whelan A, Hart LG	Obstetric practice patterns in Washington State after tort reform: has the access problem been solved?	Obstet Gynecol	12-01-1990	URL	Obstetrical Access in Washington State	We surveyed all potential obstetric providers in Washington state in the spring of 1989 to determine whether the passage of tort reform in 1986 had improved access to care for rural and medically indigent women. We found that, although the exodus of family physicians from obstetric practice that had been observed between 1985-1986 appears to have slowed, there is still substantial net attrition among family physicians. As a result, rural patients are having increasing difficulty obtaining local access to obstetric care. By contrast, the supply of obstetricians and midwives seems to be stable. All three groups of providers are increasingly reluctant to provide care to the growing number of Medicaid patients. Although tort reform may have slowed the rate at which providers are quitting obstetrics, equilibrium has not yet been achieved. Shortages of rural physicians and inadequate Medicaid reimbursement rates must be addressed to improve obstetric access for underserved groups. Access to Care Complete Journal Article Nursing Physicians RHRC Washington Medicaid medically indigent midwives obstetric practice obstetric providers obstetricians Physicians reimbursements rural tort reform
Rosenblatt RA, Whelan A, Hart LG	Rural obstetrical access in Washington State: have we attained equilibrium?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-1990		Obstetrical Access in Washington State
Skillman SM, Keppel GA, Doescher MP, Kaplan L, Andrilla CHA	Assessing rural-urban nurse practitioner supply and distribution in 12 states using available data sources	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-2015	Policy brief	Assessing rural-urban nurse practitioner supply and distribution in 12 states using available data sources
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG	Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians	J Am Board Fam Pract	01-01-1996	URL	National Health Service Corps Evaluation	BACKGROUND: This report addresses the long-term career paths and retrospective impressions of a cohort of family physicians who served in rural National Health Service Corps (NHSC) sites in return for having received medical school scholarships during the early 1980s. METHODS: We surveyed all physicians who graduated from medical school between 1980 and 1983, received NHSC scholarships, completed family medicine residencies, and served in rural areas. Two hundred fifty-eight physicians responded to our survey with complete information, 76 percent of the members of the cohort who could be located and met the study criteria. RESULTS: In 1994 one quarter of the respondents were still practicing in the county to which they had been assigned by the NHSC, an average of 6.1 years after the end of their obligation. Another 27 percent were still in rural practice. Of the entire group, less than 40 percent were in traditional urban private or managed care settings. CONCLUSIONS: Although only one quarter of NHSC assignees remain long term in their original assignment counties, they provide a large (and growing) amount of nonobligated service to those areas. Of those who leave, many remain in rural practice or work in community-oriented urban practices. Access to Care Complete Journal Article Methods National Physicians RHRC family medicine residency family physicians NHSC scholarship rural
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG	Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians	J Am Board Fam Pract	01-01-1996	URL	National Health Service Corps Evaluation
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG	Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1995		National Health Service Corps Evaluation
Muus KJ, Geller JM, Ludtke RL	Comparing urban and rural primary care PAs: implications for recruitment	J Am Acad Physician Assist	01-01-1996		National Study of Physician Assistants	ohysician assistants primary care rural rural vs urban urban
Pan S, Geller JM, Muus KJ, Hart LG	Predicting the degree of rurality of physician assistant practice location	Hosp Health Serv Adm	04-01-1996	URL	National Study of Physician Assistants	This study used a block multiple regression analysis to examine the impacts of different factors on the degree of rurality of physician assistants’ (PAs’) practice location and compared the power of each block of factors in predicting rurality. Differences in the models for PAs in primary care specialties and for PAs as a whole were also explored. The findings suggest that policies should provide support to PA students in primary care specialties and to rural-oriented PA education/training programs. Efforts to facilitate PA recruitment and retention should include, among other things, increasing practice responsibility/autonomy, broadening acceptance of PA prescriptive authority, and providing equitable reimbursement for nonphysician care of Medicare and Medicaid beneficiaries. Allied Health Complete Journal Article Methods National RHRC physician assistants practice location rural
Chan L, Hart LG, Ricketts TC, Beaver SK	An analysis of Medicare's incentive payment program for physicians in health professional shortage areas	J Rural Health	01-01-2004	URL	Medicare Bonus Payments for Physician Care in HPSAs	CONTEXT: Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. PURPOSE: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program‘s utilization and which types of physicians received payments. METHODS: Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA). FINDINGS: There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments 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. CONCLUSIONS: The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers 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, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility. Access to Care Alaska Complete Idaho Journal Article Physicians RHRC Washington Health Professional Shortage Area (HPSA) Medicare Incentive Payment (MIP) North Carolina primary care physicians rural South Carolina urban
Chan L, Hart LG, Ricketts TC, Beaver SK	An analysis of Medicare's incentive payment program for physicians in health professional shortage areas	J Rural Health	01-01-2004	URL	Medicare Bonus Payments for Physician Care in HPSAs	CONTEXT: Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. PURPOSE: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program‘s utilization and which types of physicians received payments. METHODS: Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA). FINDINGS: There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments 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. CONCLUSIONS: The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers 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, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility. Access to Care Alaska Complete Idaho Journal Article Physicians RHRC Washington Health Professional Shortage Area (HPSA) Medicare Incentive Payment (MIP) North Carolina primary care physicians rural South Carolina urban
Chan L, Hart LG, Ricketts TC III, Beaver SK	An analysis of Medicare's incentive payment program for physicians in health professional shortage areas	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-2003	Full report Policy brief	Medicare Bonus Payments for Physician Care in HPSAs
Chan L, Hart LG, Ricketts TC III, Beaver SK	An analysis of Medicare's incentive payment program for physicians in health professional shortage areas	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-2003	Full report Policy brief	Medicare Bonus Payments for Physician Care in HPSAs
Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM	Educating generalist physicians for rural practice: how are we doing?	J Rural Health	12-01-2000	URL	Review of the Literature on Medical Education Programs Promoting Rural Practice Location	Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to “small rural” communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves. Complete Journal Article National Physicians RHRC generalist Health Professions Shortage Area (HPSA) Physicians rural
Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM	Physician education and rural location: a critical review	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-1999	Full report	Review of the Literature on Medical Education Programs Promoting Rural Practice Location
Larson EH, Hart LG, Hummel J	Rural physician assistants: a survey of graduates of MEDEX Northwest	Public Health Rep	03-01-1994	URL	MEDEX Northwest Physician Assistant Study	Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural– and urban-practicing physician assistants are remarkably similar in most respects–income, hours worked, levels of practice satisfaction, for example–those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants. Alaska Allied Health Complete Idaho Journal Article Montana RHRC Washington physician assistants primary care rural urban
Larson EH, Hart LG, Hummel J	Rural physician assistants: results from a survey of graduates of MEDEX Northwest	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-1992		MEDEX Northwest Physician Assistant Study
Hummel J, Cortte R, Ballweg R, Larson E	Physician assistant training for Native Alaskan community health aides: the MEDEX Northwest experience	Alaska Med	10-01-1994	URL	MEDEX Northwest Physician Assistant Study	BACKGROUND-From 1980 through 1990, 16 Native Alaskan Community Health Aides and 21 non-Native Alaskans began physician assistant training at MEDEX Northwest at the University of Washington. This study was done to assess the outcome of training Native Alaskan health workers as physician assistants, specifically whether Native Alaskan graduates are working in settings that serve Alaska Natives. METHODS-The backgrounds, educational experiences and deployment locations of Native and non-Native Alaskans accepted for training were compared using MEDEX Northwest student records. The 1991 graduate survey was used to compare differences in practice setting, specialty and salary between Native and non-Native graduates working in Alaska in 1991. RESULTS-All of the non-Natives and 81% of the Natives completed the program. Of those completing the program, 100% of the Natives returned to Alaska where 91% found work as primary care physician assistants in clinics serving predominantly Native communities. By comparison 78% of the non-Native graduates returned to Alaska to work as physician assistants, 60% of them in primary care and 15% of them in predominantly Native communities. There were no significant differences in salary or benefits between Native and non-Native graduates. CONCLUSIONS-Physician assistant training for entry level health workers is a viable strategy for increasing the number of under-represented minorities in the health professions. The Native graduates of MEDEX Northwest are returning to communities where they serve Native people both as health care providers and as professional role models. Alaska Allied Health Complete Idaho Journal Article Montana RHRC Washington MEDEX Native Alaskan physician assistants primary care
Pirani MJ, Hart LG, Rosenblatt RA	Physician perspectives on the causes of rural hospital closure, 1980-1988	J Am Board Fam Pract	11-01-1993	URL	Physician Perceptions of the Closing of their Small Rural Hospitals	BACKGROUND: Few studies seeking to determine the causes of rural hospital closure have examined the opinions of individuals intimately involved with the closed facilities. The purpose of this research was to examine the reasons for small sole community general hospital closures from the perspective of local physicians and to compare these reasons with the perceptions of local mayors. METHODS: Hospitals in this study were selected from a list provided by the American Hospital Association. A two-page questionnaire was sent to every physician who had practiced in the towns in which a sole community general hospital had closed between 1980 and 1988. RESULTS: Physicians reported government reimbursement policies as the most important reasons for hospital closure, agreeing with the mayors’ opinions. Other reasons cited were general financial difficulties, competition from other hospitals, and bad board leadership. More than three-quarters of the physicians surveyed considered the quality of care provided by their facilities to be average or better. CONCLUSIONS: The closure of rural hospitals that physicians consider of average or better quality suggests that many of the closed hospitals could have continued to provide valuable services to the residents of their communities. Efforts must be made to ensure that rural communities are not losing viable and useful facilities. Comment in Causes of rural hospital closure. [J Am Board Fam Pract. 1993] Access to Care Complete Hospitals Journal Article National Physicians RHRC general hospitals hospital closures Physicians rural rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA	Causes and consequences of rural small hospital closures from the perspectives of mayors	J Rural Health	06-01-1991	URL	Mayor Perceptions of the Closing of their Small Rural Hospitals	Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community’s economy. Access to Care Complete Hospitals Journal Article National RHRC closures management Physicians reimbursement rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA	Causes and consequences of rural small hospital closures from the perspectives of mayors	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-01-1990		Mayor Perceptions of the Closing of their Small Rural Hospitals
Hart LG, Dobie SA, Baldwin LM, Pirani MJ, Fordyce M, Rosenblatt RA	Rural and urban differences in physician resource use for low-risk obstetrics	Health Serv Res	10-01-1996	URL	Low-Risk Obstetric Care Resource Use	OBJECTIVE: To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties. DATA SOURCES/STUDY DESIGN: A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed. FINDINGS/CONCLUSIONS: Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia). Access to Care Complete Journal Article Physicians RHRC Washington family physicians intrapartum obstetricians obstetrics prenatal rural rural vs urban
Hart LG, Dobie SA, Baldwin LM, Pirani MJ, Fordyce MA, Rosenblatt RA	Rural and urban differences in physician resource use for low-risk obstetrics	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-1995		Low-Risk Obstetric Care Resource Use
Larson EH, Hart LG, Goodwin MK, Geller J, Andrilla CHA	Dimensions of retention: a national study of the locational histories of physician assistants	J Rural Health	09-01-1999	URL	Physician Assistant Location and Geographic Trajectories: A National Study	This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as “all rural,” “all urban,” “urban to rural” or “rural to urban.” The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance. Access to Care Allied Health Complete Journal Article Montana RHRC physician assistants recruitment retention rural urban
Larson EH, Hart LG, Goodwin MK, Geller J, Andrilla CHA	Dimensions of retention: a national study of the locational histories of physician assistants	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1998	Full report	Physician Assistant Location and Geographic Trajectories: A National Study
Rosenblatt RA, Weitkamp G, Lloyd M, Schafer B, Winterscheid LC, Hart LG	Why do physicians stop practicing obstetrics? The impact of malpractice claims	Obstet Gynecol	08-01-1990	URL	Impact of Malpractice Claims
Rosenblatt RA, Weitkamp G, Lloyd M	Are rural family physicians less likely to stop practicing obstetrics than their urban counterparts: the impact of malpractice claims	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1990		Impact of Malpractice Claims
Doescher MP, Fordyce MA, Skillman SM, Jackson JE, Rosenblatt RA	Policy brief: persistent primary care health professional shortage areas (HPSAs) and health care access in rural America	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-30-2009	Policy brief	Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America
Hart LG, Pirani MJ, Rosenblatt RA	Most rural towns lost physicians after their hospitals closed	Rural Development Perspectives	10-01-1994	URL	Impact of Hospital Closures on Physician Supply	Between 1980 and 1988,132 rural hospitals closed, and left their towns with no general hospital. Most of those towns also lost physicians, and 19 were left with no physicians 2 years after closure. The smaller, more remote towns had few physicians to begin with and were more likely than larger towns to lose physicians along with their hospitals. Access to Care Complete Hospitals Journal Article National Physicians RHRC Physicians rural rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA	Rural hospital closure and physician supply: a national study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	12-01-1991		Impact of Hospital Closures on Physician Supply
Andrilla CHA, Hart LG	Results of the 2004 health center expansion and recruitment survey for health centers: analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI states)	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-14-2006	Full report	Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)
WWAMI Rural Health Research Center, University of Washington	Project summary: family physician vacancies in federally funded health centers		11-01-2005	Policy brief	Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
WWAMI Rural Health Research Center, University of Washington	Project summary: dentist vacancies in federally funded health centers	WWAMI Rural Health Research Center, University of Washington	12-01-2005	Policy brief	Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
	Project summary: registered nurse vacancies in federally funded health centers	WWAMI Rural Health Research Center, University of Washington	12-01-2006	Policy brief	Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
Andrilla CHA, Hart LG	Health Center Expansion and Recruitment Survey 2004: results by Health and Human Services regions and health center geography	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2007	Full report	Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
Rosenblatt RA, Andrilla CHA, Curtin T, Hart LG	Shortages of medical personnel at community health centers: implications for planned expansion	JAMA	03-01-2006	URL	Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project	Context The US government is expanding the capacity of community health centers (CHCs) to provide care to underserved populations. Objective To examine the status of workforce shortages that may limit CHC expansion. Design and Setting Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia, conducted between May and September 2004. Questionnaires were completed by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative. Main Outcome Measures Staffing patterns and vacancies for major clinical disciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment. Results Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equivalents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty filling positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities. Conclusions CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues. Residents of the United States lack universal access to health care, and millions of people have difficulty obtaining medical care.¹^,2 The year 2005 marked the 40th anniversary of one of the nation’s most enduring attempts to remedy this problem: the creation of community health centers (CHCs) as part of the “war on poverty.”³^– 8 The national importance of these centers has grown during the ensuing 4 decades, and the federal government provides funding through a variety of categorical mechanisms under the collective term federally qualified health centers. CHCs provide medical, dental, and mental health care for migrant workers, the uninsured, the homeless, and others in need, and the number of people they have served has expanded rapidly in the 21st century.⁹ The role and responsibility of CHCs have increased as more people in the United States have difficulty gaining access to medical care.¹⁰ CHCs now provide care to more than 14 million US residents in more than 3500 communities.⁹ Governed by nonprofit boards with majority representation from the patient population served, CHCs are different from the private practices and for-profit entities that deliver most ambulatory care in the United States.¹¹ A national decision to invest further in CHCs has occurred during a period when access to health care in the United States is limited for more people than ever before in the country’s history.¹⁰^,12^,13 Ongoing plans include a 5-year initiative that will increase federal spending on CHCs by at least $2.2 billion through fiscal year 2006 and substantially increase the number of treated patients.¹⁴^– 17 We examined the status of the health care workforce in CHCs in the United States, with particular attention to the types of personnel who are most difficult to recruit and retain. Rural health care delivery systems are smaller and less well staffed than their urban counterparts; 20% of the US population lives in rural areas but only 9% of physicians practice there.¹⁸^,19 We therefore also examined whether workforce shortages are more acute in rural CHCs and whether rural and urban CHCs differ in their staffing patterns, the source of their clinicians, and their ability to retain clinicians. Access to Care Allied Health Complete Journal Article Mental Health Methods National Nursing Oral Health Other Work Settings Other/Multiple Pharmacy Physicians RHRC CHC community health centers nonphysician clinicians Physicians primary care rural underserved urban workforce
Dobie SA, Hagopian A, Kirlin BA, Hart LG	Wyoming physicians are significant providers of safety net care	J Am Board Fam Pract	11-01-2005	URL	Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?	Background: This study describes the contributions of family and general practice physicians from Wyoming to the health care safety net. Methods: We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. Two-tailed 2 tests and limited logistic regressions were used to test for differences among characteristics of safety net providers. Results: From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women are less likely than men to make this mean income, even when controlling for hours worked (OR, 0.09; CI, 0.009, 0.862). 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. Conclusions: Wyoming family and general practice physicians provide significant amounts of informal safety net care, which is threatened by income loss. Thoughtful public policy is needed to ensure that vulnerable rural Americans have access to care that is not tied to the financial well being of their health care providers. ( J Am Board Fam Pract 2005;18:470 –7.) Access to Care Alaska Complete Idaho Journal Article Physicians RHRC Wyoming charity care family practice general practice Physicians primary care rural safety net underinsured uninsured
Dobie SA, Hagopian A, Kirlin BA, Hart LG	Wyoming physicians offer significant amounts of safety net care in their communities	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2006	Full report	Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?
Rosenblatt RA, Chen FM, Lishner DM, Doescher MP	The future of family medicine and implications for rural primary care physician supply	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-30-2010	Full report Policy brief	The Future of Family Medicine and Implications for Primary Care Physician Supply
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG	The effect of federal grants on medical schools' production of primary care physicians	Am J Public Health	03-01-1993	URL	Relationship Between Federal Funding and Medical School Output	OBJECTIVES. Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. METHODS. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. RESULTS. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. CONCLUSIONS. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes. Complete Journal Article Methods National Physicians RHRC family medicine medical schools primary care physicians
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG	The effect of federal grants on medical schools' production of primary care physicians	Am J Public Health	03-01-1993	URL	Relationship Between Federal Funding and Medical School Output	OBJECTIVES. Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. METHODS. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. RESULTS. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. CONCLUSIONS. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes. Complete Journal Article Methods National Physicians RHRC family medicine medical schools primary care physicians
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG	Which medical schools produce rural physicians?	JAMA	09-01-1992	URL	Relationship Between Federal Funding and Medical School Output	Objective. —To examine the hypothesis that medical schools vary systematically and predictably in the proportion of their graduates who enter rural practice. Design. —The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools—including location, ownership, and funding—were linked to the Physician Masterfile. Main Outcome Measures. —The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty. Results. —Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health. Discussion. —The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.(JAMA. 1992;268:1559-1565) Complete Journal Article Methods National Physicians RHRC medical schools Physicians practice location primary care rural specialties urban
Whitcomb ME, Cullen TJ, Hart LG, Lishner DM, Rosenblatt RA	Comparing the characteristics of schools that produce high percentages and low percentages of primary care physicians	Acad Med	09-01-1992	URL	Relationship Between Federal Funding and Medical School Output	To examine whether the medical school environment is important in influencing students to choose careers in primary care, the authors in 1991 compared certain characteristics of the environments of schools that produced high percentages of primary care physicians with those of schools that produced low percentages over a five-year period. The authors used the American Medical Association Physician Masterfile to identify the percentage of graduates of each of 121 medical schools for the period 1981–1985 who entered primary care specialties. They then compared the 25 schools that produced low percentages (22–29%) with the 25 schools that produced high percentages (39–56%). The results demonstrate important differences between the two groups of schools in their commitments to primary care education, their research programs, and their clinical environments supporting required clerkships. The authors conclude that a school’s educational environment is an important factor in influencing some students to pursue careers in primary care medicine. Complete Journal Article Methods National Physicians RHRC educational environment medical schools Physicians primary care specialties
Whitcomb ME, Cullen TJ, Hart LG, Lishner DM, Rosenblatt RA	Impact of federal funding for primary care medical education on medical student specialty choices and practice locations: 1976-1985	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1991		Relationship Between Federal Funding and Medical School Output
Baldwin LM, Hart LG, West PA, Norris TE, Gore E, Schneeweiss R	Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations	J Rural Health	11-01-1995	URL	Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs	This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates’ broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women. Complete Journal Article National Physicians RHRC family medicine graduates practice location residency rural vs urban
Baldwin LM, Hart LG, Norris TE, West P, Gore E, Schneeweiss R	Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban places	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-1993		Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs
Hart LG, Norris TE, Lishner DM	Attitudes of family physicians in Washington State toward physician-assisted suicide	J Rural Health	09-01-2003	URL	Family Physician Attitudes Toward Physician-Assisted Suicide	CONTEXT: The topic of physician-assisted suicide is difficult and controversial. 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. PURPOSE: This paper utilizes data from a 1997 survey of family physicians (FPs) in Washington State to test two hypotheses: (1) older respondents will indicate greater opposition to physician-assisted suicide than their younger colleagues, and (2) male and rural physicians will have more negative attitudes toward physician-assisted suicide than their female and urban counterparts. METHODS: A questionnaire administered to all active FPs obtained a 68% response rate, with 1074 respondents found to be eligible in this study. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. FINDINGS: 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% indicated that they did not know. Fifty-eight percent of the study sample reported that they would not include physician-assisted suicide in their practices even if it were legal. Responses disaggregated by age-groups closely paralleled the group overall. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents. Even among those reporting support for physician-assisted suicide, many expressed reluctance about including it in their practices. CONCLUSIONS: These findings highlight the systematic differences in FP attitudes toward one aspect of health care by gender, rural–urban practice location, and other factors. Complete Journal Article Physicians RHRC Washington age educational background euthanasia family physicians gender general practitioners health care Oregon physician-assisted suicide Physicians practice characteristics rural urban
Hart LG, Norris TE, Lishner DM	Attitudes of family physicians in Washington State toward physician-assisted suicide	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-2002	Full report Policy brief	Family Physician Attitudes Toward Physician-Assisted Suicide
West PA, Norris TE, Gore EJ, Baldwin LM, Hart LG	The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network	J Am Board Fam Pract	03-01-1996	URL	Geographic Career Trajectories of Family Practice Physicians	BACKGROUND: There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort. METHODS: Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations. RESULTS: Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier. CONCLUSIONS: The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future. Complete Journal Article National Physicians RHRC family physicians generalist physicians Physicians practice location rural underserved urban
West P, Norris TE, Gore E, Baldwin LM, Hart LG	The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	02-01-1995		Geographic Career Trajectories of Family Practice Physicians
Rosenblatt RA, Wright GE, Baldwin LM	The effect of the doctor-patient relationship on emergency department use among the elderly	Am J Public Health	01-01-2000	URL	The Emergency Care of the Rural Elderly	OBJECTIVES: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician. METHODS: The Health Care Financing Administration’s National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994. RESULTS: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician. CONCLUSIONS: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician–regardless of specialty–may reduce emergency department use. Complete Health Care Outcomes and Quality Journal Article Physicians RHRC Washington doctor-patient elderly emergency Medicare
Lishner DM, Rosenblatt RA, Baldwin LM, Hart LG	Emergency department use by the rural elderly	J Emerg Med	04-01-2000	URL	The Emergency Care of the Rural Elderly	This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. 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. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Complete Health Care Outcomes and Quality Journal Article Physicians RHRC Washington diagnoses elderly emergency Medicare rural
Lishner DM, Rosenblatt RA, Baldwin LM, Hart LG	Emergency department use by the rural elderly	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-1998	Full report	The Emergency Care of the Rural Elderly
Skillman SM, Kaplan L, Andrilla CHA, Ostergard S., Patterson DG	Support for rural recruitment and practice among U.S. nurse practitioner education programs	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	05-01-2014	Policy brief	What Strategies Are Nurse Practitioner Educational Programs Using to Encourage Rural Practice?
Larson EH, Murowchick E, Hart LG	Did rural perinatal care systems stay regionalized between 1985 and 1997?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-20-2010	Full report	Are Rural Perinatal Care Systems Deregionalizing?
Doescher MP, Andrilla CHA, Skillman SM, Morgan P, Kaplan L	The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey	Med Care	05-21-2014	URL	The Current Contribution of Physicians, Advanced Practice Nurses, and Physician Assistants to the Rural Primary Care Workforce	Background: Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. Objectives: For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. Methods: A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and χ² testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. Results: Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage (all P<0.001). Conclusions: Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting. Allied Health Complete Journal Article National Nursing Physicians RHRC health care workforce outpatient visit quantity primary care rural populations
Patterson DG, Skillman SM	National Consensus Conference on Community Paramedicine: summary of an expert meeting	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-07-2013	Full report	National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda
Patterson DG, Skillman SM	A national agenda for community paramedicine research	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-06-2013	Full report	National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda
Jackson JE, Doescher MP, Hart LG	A national study of lifetime asthma prevalence and trends in metro and non-metro counties, 2000-2003	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2007	Full report Policy brief	The Burden of Chronic Illness Among Rural Residents: A National Study
Skillman SM, Palazzo L, Hart LG, Butterfield P	Changes in the rural registered nurse workforce from 1980 to 2004	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	10-01-2007	Full Report Policy Brief	Long-Term Trends in Characteristics of the Rural Nurse Workforce: A National Health Workforce Study
Fordyce MA, Doescher MP, Chen FM, Hart LG	Osteopathic physicians and international medical graduates in the rural primary care physician workforce	Fam Med	06-01-2012	URL	National Changes in Physician Supply	BACKGROUND AND OBJECTIVES: Primary care physician (PCP) shortages are a longstanding problem in the rural United States. This study describes the 2005 supply of two important components of the rural PCP workforce: rural osteopathic (DO) and international medical graduate (IMG) PCPs. METHODS: American Medical Association (AMA) and American Osteopathic Association (AOA) 2005 Masterfiles were combined to identify clinically active, non-resident, non-federal physicians aged 70 or younger. Rural-Urban Commuting Area codes were used to categorize practice locations as urban, large rural, small rural, or isolated small rural. National- and state-level analyses were performed. PCPs included family physicians, general internists, and general pediatricians. RESULTS: DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce, although their relative representation varied geographically. DO PCPs were more likely than allopathic PCPs to practice in rural places (20.5% versus 14.9%, respectively). IMG PCPs were more likely than other PCPs to practice in rural persistent poverty locations (12.4% versus 9.1%). The proportion of rural PCP workforce represented by DOs increased with increasing rurality and that of IMGs decreased. CONCLUSIONS: DO and IMG PCPs constitute a vital portion of the rural health care workforce. Their ongoing participation is necessary in addressing existing rural PCP shortages and handling the influx of newly insured residents as the Patient Protection and Affordable Care Act (ACA) comes into effect. The impact on rural DO and IMG PCP supply of ACA measures intended to increase their numbers remains to be seen. Complete Journal Article National Physicians RHRC IMG international medical graduate osteopathic PCP Primary care physician rural workforce
Fordyce MA, Chen FM, Doescher MP, Hart LG	2005 physician supply and distribution in rural areas of the United States	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	11-01-2007	Full report Policy brief	National Changes in Physician Supply
Chan L, Giardino M, Rubenfeld G, Baldwin LM, Fordyce MA, Hart LG	Geographic differences in use of home oxygen for obstructive lung disease: a national Medicare Study	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-03-2008	Full report Policy brief	National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?
Chan L, Giardino N, Rubenfeld G, Baldwin LM, Fordyce MA, Hart LG	Geographic differences in use of home oxygen for obstructive lung disease: a national Medicare study	J Rural Health	03-01-2010	URL	National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?	RATIONALE: Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year). OBJECTIVES: To assess geographic differences in supplemental oxygen use. METHODS: Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lungdisease in 1999 and alive at the end of 2000. MEASUREMENTS AND MAIN RESULTS: While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas. CONCLUSIONS: There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility. Complete Health Care Outcomes and Quality Journal Article National RHRC chronic obstructive pulmonary disease durable medical equipment health services accessibility oxygen inhalation therapy pulmonary disease rural health services
Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N, Chan L	Quality of care for acute myocardial infarction in rural and urban U.S. hospitals	J Rural Health	01-01-2004	URL	Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995	CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals‘ patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI. Complete Health Care Outcomes and Quality Hospitals Journal Article National Physicians RHRC acute myocardial infarction (AMI) hospital rural urban
Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N, Chan L	Quality of care for acute myocardial infarction in rural and urban U.S. hospitals	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-2002	Full report Policy brief	Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995
Doescher MP, Jackson JE	Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States	J Public Health Manag Pract	05-01-2009	URL	Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?	Objective: The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening. Methods: Data from the Behavioral Risk Factor Surveillance System (1994–2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location. Results: In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening. Conclusions: Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed. Policy Implications: Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status. Access to Care Complete Journal Article National RHRC breast cancer screening cervical cancer screening prevalence rural location trends
Doescher MP, Jackson JE	Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-2008	Full report Policy brief	Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?
Baldwin LM, Cai Y, Larson EH, Dobie SA, Wright GE, Goodman DC, Matthews M, Hart LG	Access to cancer services for rural colorectal cancer patients	J Rural Health	10-01-2008	URL	Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study	CONTEXT: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancercare services–surgery, medical oncology consultation, and radiation oncology consultation. METHODS: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patientsbypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment. Access to Care Complete Hospitals Journal Article National Physicians RHRC cancer care colorectal cancer rural urban
	Project summary: access to cancer services for rural colorectal cancer patients.	Seattle, WA - WWAMI Rural Health Research Center, University of Washington	10-31-2007	Policy brief	Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study
Baldwin LM, Grossman DC, Casey S	Perinatal and infant health among rural and urban American Indians/Alaska Natives	Am J Public Health	09-01-2002	URL	Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women	OBJECTIVES: We sought to provide a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health. METHODS: In this cross-sectional study of all 1989-1991 singleton AI/AN births to US residents, we compared receipt of an inadequate pattern of prenatal care, low birthweight (< 2500 g), infant mortality, and cause of death for US rural and urban AI/AN and non-AI/AN populations. RESULTS: Receipt of an inadequate pattern of prenatal care was significantly higher for rural than for urban mothers of AI/AN infants (18.1% vs 14.4%, P </=.001); rates for both groups were over twice that for Whites (6.8%). AI/AN postneonatal death rates (rural = 6.7 per 1000; urban = 5.4 per 1000) were more than twice that of Whites (2.6 per 1000). CONCLUSIONS: Preventable disparities between AI/ANs and Whites in maternal and infant health status persist. Access to Care Complete Health Care Outcomes and Quality Journal Article National RHRC Alaska Native American Indian child Indian Health Service (IHS) infant infant death prenatal care rural urban urban health
Baldwin LM, Casey S, Freeman W	Perinatal and infant health among rural and urban American Indians/Alaska Natives	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-1999	Full report. Policy brief.	Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women
Rosenblatt RA, Hagopian A, Andrilla CHA, Hart LG	Project summary: will rural family medicine residency training survive?	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	01-01-2007	Policy brief.	Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study
Rosenblatt RA, Hagopian A, Andrilla CHA, Hart LG	Will rural family medicine residency training survive?	Fam Med.	11-01-2006	URL	Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study	BACKGROUND AND OBJECTIVES: Rural family medicine residencies may be more threatened by declining interest in family medicine than their urban counterparts. This study examines the recent performance of rural residencies in the National Resident Matching Program as an indicator of their viability. METHODS: We surveyed all 30 family medicine residencies located in rural areas during the summer of 2004 and a geographically matched sample of 31 urban residencies. We gathered information about the matching process for 2002, 2003, and 2004. The response rate was 70.5%. RESULTS: Rural programs offer about one third fewer first-year (postgraduate year 1 [PGY-1]) positions than their urban counterparts. Ruralprograms had lower Match rates (60.1%) than urban programs (72.5%) in 2004 but no meaningful differences in the proportion of international medical graduates (IMGs) or osteopathic physicians (DOs) who ultimately accepted positions. The 44.2% of residencies that predicted they would be thriving 2 years in the future filled an average of 81.3% of their slots on Match Day; there were no rural/urban differences. Programs with less-optimistic appraisals of their future had much lower Match rates. Two factors were associated with lower Match rates when other variables were taken into account: the proportion of IMGs in the 2 previous entering years and a stated rural mission. CONCLUSIONS: Rural programs appear to be slightly less stable than their urban counterparts, but the differences are minor. The viability of rural family medicine residency programs is probably affected more by the overall attractiveness of family medicine as a discipline rather than the rural or urban location of the residency. Complete Journal Article National Physicians RHRC family medicine National Resident Matching Program residency rural rural vs urban
Saver BG, Bowman R, Crittenden RA, Maudlin RK, Hart LG	Barriers to residency training of physicians in rural areas	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-1998	Full report	Barriers to Rural Residencies Project
Kaplan L, Skillman SM, Fordyce MA, McMenamin PD, Doescher MP	Understanding APRN distribution in the United States using NPI data	J Nurse Pract	09-14-2012	URL	Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.	This study examined the 2010 Centers for Medicare and Medicaid Services National Plan and Provider Enumeration System’s National Provider Identifier (NPI) data to ascertain their usefulness to determine the distribution of advanced practice registered nurses (APRNs) in rural and urban areas of the United States. This study showed that certified registered nurse anesthetists were more likely to practice in rural areas in states with greater practice autonomy. For nurse practitioners, the findings were similar but were of borderline statistical significance. These findings imply that practice autonomy should be considered as a state-level strategy to encourage rural practice by APRNs. CHWS Complete Journal Article National Nursing RHRC APRN autonomy APRN workforce certified registered nurse anesthetists national provider identifier nurse practitioners
Skillman SM, Kaplan L, Fordyce MA, McMenamin PD, Doescher MP	Understanding advanced practice registered nurse distribution in urban and rural areas of the United States using National Provider Identifier data	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	04-01-2012	Full report. Policy brief.	Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.
Rosenblatt RA, Baldwin LM, Chan L	The quality of care received by diabetic patients in Washington State: a rural-urban comparison	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2000	Full report. Policy brief.	Ambulatory Care and the Rural Elderly
Rosenblatt RA, Baldwin LM, Chan L	The quality of care received by diabetic patients in Washington State: a rural-urban comparison	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	03-01-2000	Full report. Policy brief.	Ambulatory Care and the Rural Elderly
Rosenblatt RA, Baldwin LM, Chan L	Improving the quality of outpatient care for older patients with diabetes: Lessons from a comparison of rural and urban communities	J Fam Pract.	08-01-2001	URL	Ambulatory Care and the Rural Elderly	Objective To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs). Study Setting Community health centers within the 50 states and Washington, DC. Study Design Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit. Data Collection 2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011. Principal Findings Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians. Conclusions Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider. Access to Care Complete Journal Article Physicians RHRC Washington
Rosenblatt RA, Baldwin LM, Chan L	Improving the quality of outpatient care for older patients with diabetes: Lessons from a comparison of rural and urban communities	J Fam Pract.	08-01-2001	URL	Ambulatory Care and the Rural Elderly	Objective To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs). Study Setting Community health centers within the 50 states and Washington, DC. Study Design Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit. Data Collection 2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011. Principal Findings Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians. Conclusions Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider. Access to Care Complete Journal Article Physicians RHRC Washington
Fordyce MA, Doescher MP, Skillman SM	Aging rural physician workforce	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	09-30-2013	Full report.	The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?
Doescher MP, Fordyce MA, Skillman SM	Aging rural physician workforce	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	06-01-2009	Policy brief.	The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?
Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG	Access to and Outcomes of Obstetric Care	Am J Public Health.	01-01-1997	URL	Relationship Between Access to Obstetrical Care and Process and Outcome of Care	OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources. Access to Care Complete Health Care Outcomes and Quality Journal Article Physicians RHRC Washington access maternity care neonatal obstetric care rural
Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG	Access to and Outcomes of Obstetric Care	Am J Public Health.	01-01-1997	URL	Relationship Between Access to Obstetrical Care and Process and Outcome of Care	OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources. Access to Care Complete Health Care Outcomes and Quality Journal Article Physicians RHRC Washington access maternity care neonatal obstetric care rural
Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG	Access to and Outcomes of Obstetric Care	Seattle, WA: WWAMI Rural Health Research Center, University of Washington	08-01-1993		Relationship Between Access to Obstetrical Care and Process and Outcome of Care

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Authors	Title	Published by	Date	Article link	Related Studies
Prusynski RA, Mroz TM, Frogner BK	Differences in staffing for non-nursing occupations across U.S. skilled nursing facilities during 2018-2023	Center for Health Workforce Studies, University of Washington	09-18-2024	Full Report	Staffing of Allied Health Professionals in Skilled Nursing Facilities	This study examined variability in non-nursing occupations (e.g., respiratory, pharmacy, social work) staffing levels and contract staffing across U.S. skilled nursing facilities (SNFs) from January 2018 through June 2023 with a goal of identifying workforce gaps that might reflect potential inequities in access to care. Specifically, we estimated relationships between facility factors (e.g., region, profit status, quality, urban/rural location, payer mix) and community factors (e.g., racial/ethnic composition, social deprivation) with staffing minutes per patient-day (MPPD) and percent contractors for all non-nursing healthcare occupations in SNFs. Allied Health CHWS CHWS Home Complete Reports and Briefs
Stubbs BA, Nguyen NH, Guenther GA, Skillman SM	Washington’s Health Workforce Sentinel Network: Summary of Spring 2024 Findings	Center for Health Workforce Studies, University of Washington	06-13-2024	Washington Health Workforce Sentinel Network Summary of Spring 2024 Findings	Health Workforce Sentinel Network	High-Level Findings From Spring 2024 Employers are increasingly reporting that they are creating their own training programs or are implementing models based on apprenticeships and mentorships to “grow their own” employees. Lower wage occupations, such as nursing assistants, medical assistants and dental assistants, are reported to be difficult to hire and retain due to wage competition and, in some cases, switching to a field other than healthcare. While the overall use of contract/travel workers has decreased since the height of the COVID-19 pandemic, this strategy is still used by many Washington healthcare employers to fill staffing needs.
Bacci JL, Oster NV, Pollack SW, Skillman SM	A Qualitative Analysis of Opportunities to Strengthen Pharmacy Technician Career Pathways Across Practice Settings	American Journal of Health-System Pharmacy	08-13-2024	URL	Envisioning New Career Pathways for Pharmacy Technicians	Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To identify pharmacy technician career pathways across pharmacy practice settings and opportunities to strengthen and expand these pathways. Methods Interviews were conducted with 17 participants from national pharmacy organizations, community pharmacies, health systems, and academia from March to May 2023. Interview questions were designed to elicit participants’ perceptions of factors influencing entry into, recruitment and retention of, and advancement of the pharmacy technician workforce. Interview notes were analyzed using a rapid thematic analysis approach. Results Seven themes were identified, including 3 themes related to entry: (1) healthcare interest and prior exposure facilitate pharmacy technician career discovery; (2) variation in and quantity of entry-level requirements can impede entry into pharmacy technician careers; and (3) proactive promotion of pharmacy technician careers needed. Two themes were related to recruitment and retention: (4) pharmacy technician compensation not aligned with job demands and (5) career ladders or lattices create advancement opportunities. Two themes were related to professional advancement: (6) pharmacy technician advancement limited by weak professional identity and (7) scope-of-practice policies can facilitate pharmacy technician advancement. Conclusion This study highlights the challenges pharmacy technicians face in their careers. Key findings stress cultivating a professional identity for pharmacy technicians, establishing career ladders or lattices, and advocating for policies that facilitate pharmacy technician professional advancement. These efforts are vital for sustaining the pharmacy technician workforce and ensuring quality patient care amidst the changing landscape of the pharmacy profession.
Bacci JL, Oster NV, Skillman SM	Insights into Decreasing Applicants to Schools and Colleges of Pharmacy in the United States	Center for Health Workforce Studies, University of Washington	08-16-2024	Full Report	What is Driving the Enrollment Crisis at Schools and Colleges of Pharmacy	This study sought to explore recent declines in pharmacy school applications by describing factors that influence undergraduate students’ decision to study pharmacy at selected research universities in the United States (US) with schools and colleges of pharmacy. Key findings include: Factors that positively influence undergraduate students’ decision to study pharmacy include the prestige of a doctorate degree, job security/stability, salary, job availability, the ability to improve people’s health and wellbeing, the opportunity to work in healthcare, and the range of possible careers within pharmacy. Family members, pharmacists, pre-pharmacy or pharmacy students, a college teacher or advisor, and pre-pharmacy clubs were more frequently reported as a positive factor in undergraduate students’ decision to apply or have an intent to apply to pharmacy compared to students who were still undecided. High tuition for pharmacy school negatively influences undergraduate students’ decision to study pharmacy. These factors can help schools and colleges of pharmacy and professional organizations develop impactful practices and policies for promoting and recruiting individuals into the pharmacy profession.
Guenther GA, Pollack SW, Stubbs BA, Frogner BK, Skillman SM	Characteristics of the Current Dental Hygienist Workforce in Washington State	Center for Health Workforce Studies, University of Washington	08-08-2024	URL	Washington Oral Health Workforce Tracking Program	Demand for dental hygienists (DHs) in Washington is high and is limiting access to dental services in the state. Using data from state licensure records and a survey of DHs in the state, along with a variety of other sources, this report provides insights into who selects dental hygiene as a career and their pathways into this important oral health occupation, descriptions of the types and locations of their work, as well as DHs’ views of their jobs and careers. Survey findings suggest that about 84% of DHs with Washington licenses were practicing as a DH in the state. Analyses focused on these respondents, and key findings include: Nearly 98% of DH respondents working in Washington were female and 78% were white. Half of the DH respondents completed an associate degree and 45% completed a bachelor’s degree in dental hygiene, and a quarter completed their dental hygiene education in a state other than Washington. Washington DHs working in public and non-profit settings, such as public health departments and community health centers, reported they worked more weekly hours on average (30.2 hours) and earned lower average hourly wages ($55.32) compared with DHs in private practices where most DHs in the state were employed (26.8 hours and $60.35). DHs in public and non-profit settings as well as DHs overall who worked more weekly hours (35 or more) reported receiving more employment benefits (including medical insurance, retirement, and paid time off) than DHs working in private settings or DHs overall who worked fewer (fewer than 35) weekly hours. When asked their views of their jobs and careers, DH respondents were generally positive, but some indicated dissatisfaction with opportunities for growth and leadership development and opportunities for promotion in their jobs. Slightly more than half (55%) strongly agreed or agreed that they would recommend a career as a DH to a friend or relative. DHs reported recording health histories, performing subgingival planing, oral inspection, and applying topical fluorides and varnishes nearly every day. Just over half of DHs reported having ever applied silver diamine fluoride and about one quarter reported having ever placed and finished restorations. Most (89%) DH respondents reported experiencing pain or discomfort in the hands, wrists, arms, shoulders, or neck in the past 12 months, with 93% of those with pain attributing it to dental hygiene work. These findings are comparable to a similar Washington survey of DHs conducted in 2004. Despite some job dissatisfaction and high rates of musculoskeletal disorders (MSDs) attributed to their work, nearly three quarters of DH respondents planned to continue working as a DH in clinical practice over the next few years. Conclusions from these findings include: Strategies to address the conditions and DH practices that contribute to MSDs could help to encourage DHs to work more weekly hours, reduce DH job vacancies, and help improve access to patient care. Extending the DH career pathway with more opportunities for advancing dental hygiene careers, including but not exclusively into dentistry, could make DH a career that attracts more, and more diverse, entrants. Ongoing tracking of the size, distribution, and characteristics of Washington’s dental workforce is important to determine if and where progress is achieved to address oral health workforce issues in the state.
Cole MB, Wright B, Kett PM, Johnson HM, Staloff J, Frogner BK	COVID-19 Federal Funding To Health Centers: Tracking Distribution, Locations, And Patient Characteristics	Health Affairs	08-05-2024	URL	How Financial Support During the COVID Crisis Affected the Federally Qualified Health Center Workforce	In 2020 and 2021, health centers received federal funding to support their COVID-19 pandemic response, yet little is known about how the funds were distributed. This study identified ten sources of funding distributed to 1,352 centers, ranging from $19 to $1.22 billion per center. When we examined patient and organizational characteristics by quartiles of funding per patient, health centers in the highest-funded quartile (quartile 4) were more likely rural and in the South; employed lower percentages of physicians; and had the highest percentages of sicker, uninsured, and unhoused patients. Centers in the lowest-funded quartile (quartile 1) were more likely urban, employed lower percentages of nurse practitioners, and had the highest percentages of Medicaid enrollees. With the end of pandemic-related funding in 2023, combined with Medicaid unwinding concerns, targeted investment is needed to mitigate a financial cliff and help maintain health centers’ capacity to provide high-quality services to those most in need.
Kett PM, Cole MB, Wright B, Frogner BK	Association of Federal COVID-19 Funding Distributions With Workforce and Capacity in Health Centers	Journal of Ambulatory Care Management	08-01-2024	URL	How Financial Support During the COVID Crisis Affected the Federally Qualified Health Center Workforce: An Update	Using novel national data, we examined the association between 2020 federal COVID-related funding targeted to health centers (i.e., H8 funding) and health center workforce and operational capacity measures that may be important for preserving patient access to care and staff safety. We assigned health centers to quartiles based on federal funding distribution per patient and used adjusted linear probability models to estimate differences in workforce and operational capacity outcomes across quartiles from April 2020 to June 2022. We found a nearly 6-fold difference in 2020 H8 funding per patient when comparing health centers in the lowest versus highest quartiles. Despite this difference, health centers’ outcomes improved similarly across quartiles over time, with the lowest-funded health centers having the greatest staffing and service capacity challenges. Our findings suggest that COVID-related health center funding may have contributed to stabilization of health centers’ workforce and operations. Amid concerns about staff turnover, sustained investments targeted to supporting workforce retention at health centers can help to ensure ongoing delivery of critical services.
Williams-York B, Guenther GA, Patterson DG, Mohammed S, Kett PM, Dahal A, Frogner BK	Burnout, Exhaustion, Experiences of Discrimination, and Stress among Underrepresented and First-Generation College Students in Graduate Health Profession Education	Physical Therapy & Rehabilitation Journal	07-17-2024	URL	The Potential Burden of Being Underrepresented in Health Professional Programs	Objectives Mental health disorders are increasing among health profession students. Compounding this, students from underrepresented backgrounds may face additional stressors and challenges. The aims of this study were to: 1) assess the extent to which burnout, exhaustion, experiences of discrimination, and stress exist among students in dentistry, nursing, occupational therapy, pharmacy, and physical therapist professional education programs; 2) determine if there are significant differences by key demographic characteristics (those who are first-generation college students [FGCS], a member of an underrepresented minority [URM] group), or both); and 3) highlight strategies and solutions to alleviate these challenges identified by students. Methods Cross-sectional survey using a mix of question types of a sample of graduate students from dentistry, nursing, occupational therapy, pharmacy, and physical therapy programs from February to June 2020. Utilizing the Maslach Burnout Inventory Student Survey (MBI-SS) and campus climate and stress survey, mean subscale scores were calculated for the following outcomes of interest: MBI-SS burnout, dimensions of stress, and observed racism. Logistic regressions examined student factors that may help explain these outcomes. Content analysis examined participants’ responses to open-ended questions. Results There were 611 individuals who completed all survey questions. FGCS were significantly more likely than non-FGCS to report exhaustion (adjusted odds ratio [AOR]: 1.50; 95% CI: 1.04–2.16), family stress (AOR: 3.11; 95% CI: 2.13–4.55), and financial stress (AOR: 1.74; 95% CI: 1.21–2.50). URM students reported not feeling supported in their program and mentioned needing additional support, particularly for well-being, from staff and faculty. Conclusion Findings from this study are consistent with literature that FGCS students experience additional stressors that may lead to burnout and exhaustion. URM students reported not feeling supported in their programs. This study’s findings point to the need for leadership and faculty of health professional schools to implement or strengthen current policies, practices, and strategies that support URM students and FGCS. Impact Research demonstrates that a diverse student body and faculty enhances the educational experience for health professional students, and that diversity strengthens the learning environment and improves learning outcomes, preparing students to care for an increasingly diverse population. However, this study finds that students from underrepresented backgrounds may still experience more burnout, exhaustion, discrimination, and stress than their peers. Programs and policies to support URM students and FGCS throughout their academic careers can help improve graduation and retention rates, leading to improved workforce diversity.
Dahal A, Frogner BK	Mental and Physical Health Status of U.S. Health Care Workers	Center for Health Workforce Studies, University of Washington	06-11-2024	Full Report	Are Allied Health Providers Sick? If So, Are There Wage Consequences Associated with Being Sick?	This study is a cross-sectional analysis of the 2017 wave of the Panel Study of Income Dynamics (PSID), which is part of a longitudinal survey of the general US population. Individuals aged 18 years or older that were employed or were actively looking for a job categorized by whether they worked in health care or not were included in the study. We examined the prevalence of self-reported mental and physical health conditions such as cardiovascular diseases, cancer and respiratory illnesses among health care professionals compared to all other employed individuals in the US. We compared health status across health care occupations and three health care settings: hospitals, ambulatory care, and long-term care. Using multivariate regressions, we examined the risk factors associated with health conditions among health care providers by occupation and work setting. Survey weights were applied to generalize results to the national population. The following were key study findings: Our sample included 10,375,357 health care workers and 104,999,133 non-health care workers. Health care workers compared to workers in other industries were slightly younger (41.7 vs 42.4), fewer were female (76.3% vs. 79.2%) and more likely to have a bachelor’s degree or higher (60.7% vs. 48.1%). Compared to workers in other industries, health care workers had a higher prevalence of any mental illness (14.6% vs. 9.6%), especially depression (8.0% vs. 4.9%) and anxiety (2.9% vs. 1.9%). Health care workers also had a higher prevalence of some physical health conditions such as other chronic illnesses (19.2% vs. 12.3%) and cancer (4.6% vs. 4.2%) compared to other workers. Among health care workers, the prevalence of 3 or more chronic illnesses was highest among those who worked in long-term care (36.9% compared to 34.9% for the overall health care group). Multivariate regression analysis showed that long-term care workers had a higher prevalence of cardiovascular diseases, diabetes, and cancer, while ambulatory care workers had higher prevalence of respiratory illnesses and hospital workers had higher prevalence of having arthritis. These prevalences were not statistically significant across settings, however. No consistent pattern or significant differences were found in the adjusted probabilities of the prevalence of physical health conditions by occupation other than physicians generally having the lowest probability of having any physical health condition except for cancer where they had the highest probability. Licensed practical nurses/licensed vocational nurses followed by aides/assistants had the highest probability of having any mental illness, including depression, compared to other occupations, though the differences were not statistically significant. Health care workers generally reported worse mental health and more comorbidities than non-health care workers, though the prevalences of physical health conditions were similar. It should be noted that given the survey relies on self-report, mental health conditions may be particularly underreported due to stigma associated with them. Nonetheless, findings from this study provide important baseline information about the prevalence of illnesses in health care workers in the pre-COVID era. Ongoing follow-up will be crucial in informing policymakers on the most prevalent mental and physical health conditions to help develop policies targeting the most at-risk health care workers.
Pollack SW, Guenther GA, Stubbs BA, Patterson DG, Frogner BK, Skillman SM	Characteristics of the Current Dental Assistant and Expanded Function Dental Auxiliary Workforces in Washington State	Center for Health Workforce Studies, University of Washington	05-20-2024	URL	Washington Oral Health Workforce Tracking Program	Dental assistants (DAs) and expanded function dental auxiliaries (EFDAs; DAs with additional training allowing them to perform expanded functions) are two key occupations supporting the oral health workforce in Washington. We surveyed registered DAs and EFDAs in Washington to learn more about the supply, distribution, and characteristics of these occupations in the state. The survey received responses from 1,240 DAs and 113 EFDAs. Key findings from respondents suggest DAs in Washington State include: DAs are primarily female, White, and in their mid-thirties, on average. Two-thirds attended private or public community college or technical school DA programs. DAs work 33 hours/week on average, and the majority indicated they were working as many hours as they would like. Most DAs received some benefits at work, with paid time off most common, followed by medical benefits and retirement. Two-thirds of respondents agreed that they would recommend a career as a DA. About a third agreed they were appropriately compensated for the work they do and less than half that they were satisfied with promotion opportunities. Among respondents, 42% indicated intent to begin education to advance to another dental occupation within five years. Workforce recruitment and retention may be enhanced by the availability of employer-provided benefits, opportunities for promotion, and satisfactory wages. Efforts to increase the diversity of the DA workforce entering the occupation through the multiple DA education and training pathways utilized by survey respondents could help the DA workforce better represent the demographics of the state population, and potentially increase supply size and address high demand. Responses from EFDAs in Washington State suggest: EFDAs are primarily female, White, and in their mid-forties, on average. EFDAs work 29 hours/week on average, and the majority indicated they were working as many hours as they would like. Almost all EFDAs received paid time off, 87% received retirement benefits, and about three quarters received medical benefits. About half agreed they were appropriately compensated for the work they do, while higher percentages agreed they have opportunities for promotion, opportunities to learn and grow, and generally enjoy their work. Very few EFDAs reported they intended to seek employment in or training for another occupation in the next five years. Because EFDAs are not currently represented by a unique federal Standard Occupation Code, they cannot be identified separately from DAs in public datasets used to understand trends in the health workforce. Improved administrative data collection and monitoring of this occupation is needed.
Shahrir S, Kett PM, Bekemeier B	Public Health Nurses in an Emergency Response: Highlighting Proficiencies and Training Needs (Blog)	Journal of Public Health Management and Practice (JPHMP) Direct	04-17-2024	Blog	The Role of Public Health Nurses in Doing Health Equity Work	Public health nurses and nurse-led local health departments possess unique skills that were important in responding to COVID-19, especially in areas related to justice, equity, diversity and inclusion, and applying evidence-based approaches. Areas for additional training were also identified to guide future public health nurse workforce development.
Kett PM, Shahrir S, Bekemeier B	Public Health Nurses’ Proficiencies and Training Needs in an Emergency Response: A Cross-Sectional Observational Study	Journal of Public Health Management and Practice (JPHMP)	05-01-2024	URL	The Role of Public Health Nurses in Doing Health Equity Work	Objective: To address gaps in understanding the public health nursing workforce regarding competencies recognized as critical during an emergency response. Design, Setting, and Participants: A cross-sectional observational study using data with information on local health department staff- and organizational-level characteristics collected from across the United States in 2021. We used logistic regression to estimate the association between 2 binary nurse-specific predictors—(1) whether the staff person was a nurse and (2) whether the staff worked in a local health department that was “nurse-led” (directed by a nurse)—and reported proficiencies important to the COVID-19 response. Models controlled for relevant local health department and community characteristics. Results: In the sample, 19% were nurses and 37% were at nurse-led health departments. Nurse versus nonnurse staff had higher odds of reporting proficiencies in skills related to Justice, Equity, Diversity, and Inclusion and in the skill “identifying/applying evidence-based approaches to address public health issues.” However, nurses, compared with their nonnurse peers, had higher odds of reporting training needs in domains related to community engagement, policy engagement, and cross-sectoral collaboration. Conversely, staff at nurse-led health departments, compared with non–nurse-led staff, had higher odds of reporting proficiencies in many of these same areas, including “collaborating across the public health system” and “influencing policies external to the organization that affect community health.” There were no areas in which nurse-led staff had lower odds of reporting proficiencies or higher odds of identifying training needs. Conclusions: Findings from this study highlight areas of strength for public health nurses, particularly strengths related to diversity, equity, and inclusion, as well as areas where more training is needed. Such findings can help guide future public health nurse workforce development as well as underscore the value of public health nursing leadership and staff at local health departments for supporting community health.
Smith D, Dula C, Fite C, Gattman N, Papadakis E, Hinton L	Washington Long-Term Care Workforce Initiative Legislative Report	Washington Workforce Training and Education Coordinating Board	12-01-2023	URL	N/A
Stubbs BA, Nguyen NH, Guenther GA, Skillman SM	Washington’s Health Workforce Sentinel Network: Summary of Fall 2023 Findings	Center for Health Workforce Studies, University of Washington	03-01-2024	Washington Health Workforce Sentinel Network Summary of Fall 2023 Findings	Health Workforce Sentinel Network	High-Level Findings From Fall 2023 Staffing gaps have caused difficulties across multiple healthcare settings, including long waiting lists for appointments, the temporary inability to provide certain services and the reduction of intake for new patients/clients, among other challenges. Employers continue to report access to childcare, housing and transportation as factors that are hard for them to influence but affect their ability to hire and retain workers. These issues can be especially challenging in rural settings. Lower wage occupations, such as nursing assistants, medical assistants and dental assistants, are reported to be difficult to hire and retain due to wage competition and, in some cases, switching to a field other than healthcare.
Dill J, Frogner BK	The Gender Wage Gap Among Healthcare Workers Across Educational and Occupational Groups	Health Affairs Scholar	12-27-2023	URL	Gender-Based Wage Gaps Among Health Care Workers: Is There a Spillover Effect?	Women perform 77% of healthcare jobs in the US, but gender inequity within the healthcare sector harms women’s compensation and advancement in healthcare jobs. Using data from 2003 to 2021 of the Annual Social and Economic Supplement of the Current Population Survey (CPS), we measure women’s representation and the gender wage gap in healthcare jobs by education level and occupational category. We find descriptively that women’s representation in healthcare occupations has increased over time in occupations that require a master’s or doctoral/professional degree (e.g., physicians, therapists), while men’s representation has increased slightly in nursing occupations (e.g., registered nurses, LPNs/LVNs, aides and assistants). The adjusted wage gap between women and men is the largest among workers in high-education healthcare (e.g., physicians, advanced practitioners) but has decreased substantially over the last 20 years, while descriptively the gender wage gap has stagnated or grown larger in some lower education occupations. Our policy recommendations include gender equity reviews within healthcare organizations, prioritizing women managers, and realigning Medicare and Medicaid reimbursement policies to promote greater gender equity within and across healthcare occupations.
Rochford H, Frogner BK	Strategies for Advancing Diversity and Inclusion in Health Services Research	AcademyHealth Blog	06-07-2023	URL	N/A	Many professional organizations are updating their Professional Code of Conduct to address concerns about sexual harrassment. A Code of Conduct is one way to address these concerns, but not the only way. This blog aims to expand the conversation and equip readers with tools to take action to create a more inclusive work environment.
Prusynski RA, Frogner BK, Rundell SD, Pradhan S, Mroz TM	Is More Always Better? Financially Motivated Therapy and Patient Outcomes in Skilled Nursing Facilities	Arch Phys Med Rehabil	08-03-2023	URL	N/A	Objective: To determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes. Design: Cohort study using 2018 Medicare administrative data. Setting and participants: 13,949 SNFs in the United States. Participants: 934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation (N=934,677). Interventions: The primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide 10 or fewer minutes of therapy above weekly reimbursement thresholds. Main outcome measures: Dichotomous indicators of successful discharge to the community vs institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relations between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume. Results: Thresholding was associated with a small positive effect on functional improvement (odds ratio 1.07; 95% CI 1.06-1.09) and community discharge (odds ratio 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (odds ratio 1.27, 95% CI 1.18-1.35). Conclusions: Patients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients. Keywords: Functional status; Health policy; Medicare; Nursing homes; Patient discharge; Rehabilitation.
Prusynski RA, Frogner BK, Mroz TM	Staffing Trends for Non-Nursing Occupations in Skilled Nursing Facilities in the United States Between 2018-2022	Center for Health Workforce Studies, University of Washington	11-07-2023	Full Report	Staffing of Allied Health Professionals in Skilled Nursing Facilities	This study examined trends in staffing of non-nursing direct care occupations in skilled nursing facilities (SNFs) from 2018 to 2022 using the Payroll Based Journal, a publicly available data source with daily staffing information by occupation from the Centers for Medicare & Medicaid Services. Key findings include: Non-nursing occupations are a smaller proportion of all SNF staff compared to nursing occupations (i.e., registered nurses, licensed practical nurses, certified nursing assistants, and administrative and nursing support roles), such that nursing occupations accounted for about four times the staff hours compared to all non-nurse occupations. The overall and many individual non-nursing occupations experienced a decline between 2018-2022, though when measured as staffing per patient-day, declines were mitigated in part due to concurrent declines in patient census. Of the non-nursing occupations in SNFs, declines in census-adjusted staffing levels between 2018-2020 were the largest for therapy staff and feeding assistants. Contractors are employed at higher rates for non-nursing occupations than for nursing occupations in SNFs. Specific occupations such as therapy staff, medical directors, and pharmacists were comprised of over 50% contract staff. Between 2018-2022, contractor staffing decreased for non-nurse occupations while contractor staffing for nursing occupations increased. Access to Care Allied Health CHWS CHWS Home Complete HRSA News Nursing Reports and Briefs
Bacci JL, Pollack SW, Skillman SM, Odegard PS, Danielson JH, Frogner BK	Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce	Medical Care Research and Review	10-13-2023	URL	Impact of the COVID-19 Pandemic on Community Pharmacist Patient Care and Future Workforce Needs	This study sought to describe the impact of the COVID-19 pandemic on community pharmacy practice and its workforce. Interviews were conducted with 18 key informants from pharmacy associations and community pharmacists representing chain and independent pharmacy organizations across the United States from January to May 2022. Interview notes were analyzed using a rapid content analysis approach. Four themes resulted: (a) patient care at community pharmacies focused on fulfilling COVID-19 response needs; (b) pharmacists’ history as immunizers and scope of practice expansions facilitated COVID-19 response efforts; (c) workforce supply shortages impeded COVID-19 response efforts and contributed to burnout; and (d) maintaining community pharmacy workforce’s readiness will be critical to future emergency preparedness and response efforts. Formalizing scope of practice expansion policies and reimbursement pathways deployed during the COVID-19 pandemic could facilitate the community pharmacy workforce’s ability to address ongoing public health needs and respond to future public health emergencies.
Prusynski RA, Humbert A, Mroz TM	Skilled Nursing Facility Changes in Ownership and Short-Stay Medicare Patient Outcomes	JAMA Network	09-19-2023	URL	N/A	Importance Skilled nursing facility (SNF) changes in ownership are receiving attention in the national conversation regarding health care quality and oversight. SNF ownership changes have been cited as possible ways for SNFs to obscure financial arrangements and shift funds away from patient care; however, it is unclear whether ownership changes are associated with quality outcomes, especially for short-stay patients. Objective To determine which SNF characteristics are associated with changes in ownership and whether ownership changes were associated with differences in short-stay patient outcomes. Design, Setting, and Participants This cohort study was a secondary analysis of 2016 to 2019 Medicare administrative data including SNFs in the United States with complete data. Data were analyzed from January 2016 through December 2019. Exposure SNF change in ownership. Main Outcomes and Measures Outcomes of interest were facility-level risk-adjusted rates of hospital readmissions, emergency department visits, and community discharge for short-stay patients after admission to an SNF. Analyses were conducted using multivariable logistic regression and controlled interrupted time series. Results Of 11 004 SNFs, 1459 (13.26%) changed ownership between 2016 and 2019. Compared with for-profit SNFs, nonprofit and government SNFs had lower odds of changing ownership (nonprofit: odds ratio [OR], 0.40; 95% CI, 0.32-0.49; government: OR, 0.26; 95% CI, 0.17-0.41). Chain SNFs had higher odds of changing ownership than nonchain SNFs (OR, 1.38; 95% CI, 1.21-1.59). Urban SNFs with lower occupancy rates (OR per 10–percentage-point decrease, 1.19; 95% CI, 1.14-1.25), larger Medicaid populations (OR per 10–percentage-point increase, 1.17; 95% CI, 1.13-1.22), and lower staffing ratings (OR per 1-star increase on staffing rating, 1.18; 95% CI, 1.14-1.25) had higher odds of changing ownership. Descriptively, all 3 quality outcomes were worse throughout the study in SNFs undergoing ownership change compared with controls that did not change ownership. However, results of interrupted time series models found no associations between an ownership change and hospital readmissions or community discharge rates. Ownership change was associated with a short-term increase of 0.32 (95% CI, 0.03 to 0.62) percentage points in emergency department visits. Conclusions and Relevance In this cohort study of 11 004 SNFs in the US between 2016 and 2019, SNF characteristics historically associated with lower quality were more likely to change ownership; however, ownership changes were only associated with short-term increases in ED visits. These results suggest that SNF ownership changes may be a symptom, not a cause, of lower quality.
Buerhaus P, Fraher E, Frogner B, Buntin M, O’Reilly-Jacob M, Clarke S	Toward a Stronger Post-Pandemic Nursing Workforce	New England Journal of Medicine	07-21-2023	URL	N/A	The deep effects of the Covid-19 pandemic on frontline health care providers have given rise to concerns about the demands of nursing work and the appeal of nursing careers. Though these concerns have special resonance right now, this is not the first time apprehensions about the adequacy and sustainability of the U.S. nurse workforce have felt especially acute. In the mid-1990s, financial pressures in the health care industry led to changes that created stress and insecurity among hospital nurses that culminated in substantial declines in the numbers of people enrolling in and graduating from nursing education programs. Nearly a quarter-century later, we have another opportunity to turn the tide of a workforce crisis, this one induced by the Covid pandemic, but the circumstances are notably different. In June 2022, a group of 25 workforce analysts (including us) met in Bozeman, Montana, to examine the pandemic’s effect on nurses, discuss evolving scenarios, and identify strategies for strengthening the current and future workforce. CHWS CHWS Home COVID-19 Journal Article News Nursing
Islas IG, Brantley E, Portela Martinez M, Salsberg E, Dobkin F, Frogner BK	Documenting Latino Representation In The US Health Workforce	Health Affairs (Millwood)	07-06-2023	URL	N/A	We compared the representation of the four largest Latino subpopulation groups in the health workforce with that group’s representation in the US workforce, using 2016–20 data. Mexican Americans were the most underrepresented subpopulation in professions requiring advanced degrees. All groups were overrepresented in occupations requiring less than a bachelor’s degree. Among recent health professions graduates, overall Latino representation has been increasing over time Allied Health CHWS CHWS Home Journal Article National News
Patterson DG, van Eijk MS, Pollack SW, Stubbs B, Hanson C	The EMS and Community Paramedic Workforces Respond to COVID-19	Center for Health Workforce Studies, University of Washington	06-01-2023	Full Report	The Emergency Medical Services and Community Paramedic Workforces Response to COVID-19	In this study, 17 key informant experts shared their perspectives on how the emergency medical services (EMS) and community paramedicine (CP) workforces responded to COVID-19 during the first year of the pandemic, 2020. Experts also described how the pandemic has affected EMS and CP. EMS responders provide 9-1-1 emergency services, while community paramedics (CPs), typically drawn from EMS personnel, provide non-emergent public health services and augment primary care services to patients in the community. Access to Care Allied Health CHWS CHWS Home Complete HRSA Reports and Briefs
Pollack SW, Skillman SM, Mroz TM, Frogner BK	Medical Assistants’ Telehealth Roles and Skills in Primary Care During the COVID-19 Pandemic	Center for Health Workforce Studies, University of Washington	05-18-2023	Full Report	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 examined the roles of medical assistants (MAs) in the use of telehealth to deliver primary care during the COVID-19 pandemic. Through reviews of the literature and interviews with key informants, the study identified the skills and roles of MAs that supported rapid increase in the use of telehealth, policies and practices supporting these roles and skills, and longer-term needs to improve and maintain these skills and competencies. There were few mentions in the literature of MA specific roles associated with delivering telehealth. Key informants indicated that pandemic emergency rules enabled many of MAs’ roles to transfer from in-person to virtual and provided MAs with opportunities to rapidly take on new roles and increased responsibility. How and the extent to which MAs’ telehealth roles were implemented depended greatly on the size and location of the clinic facilities, and the variety and consistency of staffing at the clinics. MAs were generally not well-prepared by their education programs in specific telehealth skills and most of their telehealth training took place on-the-job. Iformants described the benefit of providing MAs with more technical training and education, with a focus on telehealth basics and general technology acumen. MAs will continue to be integral to both in-person and virtual health care teams and more roles for MAs in primary care are likely to emerge in the future. Meeting the current and growing demand for MAs across the US, however, requires increasing the supply of MAs. Without consistent availability of an MA workforce, and if turnover remains high, the path to expanded use of telehealth in primary care may be uneven. Allied Health CHWS CHWS Home Complete Health Care Outcomes and Quality HRSA News Reports and Briefs
Frogner BK, Patterson DG, Skillman SM	The workforce needed to address population health	Milbank Quarterly	05-17-2023	URL Interview	N/A	Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health. CHWS CHWS Home Journal Article News
Frogner BK	How can we make caring for older adults desirable work?	Generations Today	05-17-2023	URL	N/A	Older adults need a high functioning and dedicated team with the appropriate training to provide the best care and social support so they can have the best years to come. While many people enter these professions with a commitment to serve older adults, we need to recognize and reward their dedication by investing in their future via increased wages and benefits and new career pathways. Solutions to the workforce crisis in caring for older adults are many, so now we need the political will to make them a reality. Access to Care CHWS CHWS Home COVID-19 Journal Article News
Kett PM, Bekemeier B, Patterson DG, Schaffer K	Competencies, training needs, and turnover among rural compared with urban local public health practitioners: 2021 public health workforce interests and needs survey	American Journal of Public Health	05-17-2023	URL Editorial Infographic	Examining Local Public Health Workforce Capacity and Challenges in Addressing Population Health Needs	Objectives. To compare rural versus urban local public health workforce competencies and training needs, COVID-19 impact, and turnover risk. Methods. Using the 2021 Public Health Workforce Interest and Needs Survey, we examined the association between local public health agency rural versus urban location in the United States (n = 29 751) and individual local public health staff reports of skill proficiencies, training needs, turnover risk, experiences of bullying due to work as a public health professional, and posttraumatic stress disorder symptoms attributable to COVID-19. Results. Rural staff had higher odds than urban staff of reporting proficiencies in community engagement, cross-sectoral partnerships, and systems and strategic thinking as well as training needs in data-based decision-making and in diversity, equity, and inclusion. Rural staff were also more likely than urban staff to report leaving because of stress, experiences of bullying, and avoiding situations that made them think about COVID-19. Conclusions. Our findings demonstrate that rural staff have unique competencies and training needs but also experience significant stress. Public Health Implications. Our findings provide the opportunity to accurately target rural workforce development trainings and illustrate the need to address reported stress and experiences of bullying. Allied Health CHWS CHWS Home Journal Article Mental Health News
Dahal A, Kardonsky K, Cunningham M, Evans D, Keys T	The Effect of Rural Underserved Opportunities Program Participation on Medical Graduates' Decision to Work in Rural Areas	Academic Medicine	02-01-2023	URL	N/A	There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates’ decision to work in rural regions, adjusting for covariates to control for selection bias. CHWS Journal Article
Lee D, Pollack SM, Mroz T, Frogner BK, Skillman SM	Disability competency training in medical education	Medical Education Online	05-06-2023	URL	Disability Competency Training in Medical Education	Purpose. Lack of health care providers’ knowledge about the experience and needs of individuals with disabilities contribute to health care disparities experienced by people with disabilities. Using the Core Competencies on Disability for Health Care Education, this mixed methods study aimed to explore the extent the Core Competencies are addressed in medical education programs and the facilitators and barriers to expanding curricular integration. Method. Mixed-methods design with an online survey and individual qualitative interviews was used. An online survey was distributed to U.S. medical schools. Semi-structured qualitative interviews were conducted via Zoom with five key informants. Survey data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis. Results. Fourteen medical schools responded to the survey. Many schools reported addressing most of the Core Competencies. The extent of disability competency training varied across medical programs with the majority showing limited opportunities for in depth understanding of disability. Most schools had some, although limited, engagement with people with disabilities. Having faculty champions was the most frequent facilitator and lack of time in the curriculum was the most significant barrier to integrating more learning activities. Qualitative interviews provided more insight on the influence of the curricular structure and time and the importance of faculty champion and resources. Conclusions. Findings support the need for better integration of disability competency training woven throughout medical school curriculum to encourage in-depth understanding about disability. Formal inclusion of the Core Competencies into the Liaison Committee on Medical Education standards can help ensure that disability competency training does not rely on champions or resources. Allied Health CHWS Complete Journal Article News
LeRouge C, Shahrir S, Frogner BK	Landscape of the Health Informatics Workforce: Rapid Response Brief	Center for Health Workforce Studies, University of Washington	04-25-2023	Rapid Response Brief	N/A	Health informatics is an interdisciplinary field mixing science, innovation, and application. The ever-burgeoning health informatics field creates the need for a workforce distributed across multiple settings that can address the breadth of health information technology (HIT) functions and system interfaces while also keeping up with increasing demand for better integration and improvement of healthcare. However, the boundaries and areas of emphasis for this field are not always clear and frequently change, which creates ambiguity in defining a health informatics workforce. The workforce consists of a collection of professions and roles involved with health informatics at varying levels of administrative responsibility, patient service, and technology focus. Using a framework identifying five subdomains of the health informatics workforce, this brief focuses on the clinical informatics and public health, population health and social service informatics subdomains. In addition to shared fundamental knowledge, basic skills, and a core vocabulary related to health informatics, most roles and job titles in the health informatics workforce can be associated with specific learning needs and educational requirements. Multiple pathways to careers in health informatics exist, ranging from continuing education opportunities to targeted education programs typically at the master’s degree level. Allied Health CHWS CHWS Home Nursing Pharmacy Physicians Reports and Briefs
Al Achkar M, Dahal A, Frogner BK, Skillman SM, Patterson DG	Integrating Immigrant Health Professionals into the U.S. Healthcare Workforce: Barriers and Solutions	J Immigrant Minority Health	04-21-2023	URL	Accelerated Pathways for Internationally Educated Health Professionals	Internationally educated immigrant healthcare workers face skill underutilization working in lower-skilled healthcare jobs or outside healthcare. This study explored barriers to and solutions for integrating immigrant health professionals. Content analysis identifying key themes from semi-structured qualitative interviews with representatives from Welcome Back Centers (WBCs) and partner organizations. 18 participants completed interviews. Barriers facing immigrant health professionals included lack of access to resources, financial constraints, language difficulties, credentialing challenges, prejudice, and investment in current occupations. Barriers facing programs that assist immigrant health professionals included eligibility restrictions, funding challenges, program workforce instability, recruitment difficulties, difficulty maintaining connection, and pandemic challenges. Long-term program success depended on partner networks, advocacy, addressing prejudice, a client-centered approach, diverse resources and services, and conducting research. Initiatives to integrate immigrant health professionals require multi-level responses to diverse needs and collaborations among organizations that support immigrant health professionals, healthcare systems, labor, and other stakeholders. CHWS Journal Article
Lee D, Kett PM, Mohammed SA, Frogner BK, Sabin J	Inequitable care delivery toward COVID-19 positive people of color and people with disabilities	PLOS Glob Public Health	04-19-2023	URL Policy Brief	Exploring Health Workforce Influence on Equitable Care Delivery and Stigmatization toward COVID-19 Positive People of Color and People with Disabilities	This study aimed to explore provider observations of inequitable care delivery towards COVID-19 positive patients who are Black, Indigenous, and Other People of Color (BIPOC) and/or have disabilities and to identify ways the health workforce may be contributing to and compounding inequitable care. We conducted semi-structured interviews between April and November 2021 with frontline healthcare providers from Washington, Florida, Illinois, and New York. Using thematic analysis, major themes related to discriminatory treatment included decreased care, delayed care, and fewer options for care. Healthcare providers’ bias and stigma, organizational bias, lack of resources, fear of transmission, and burnout were mentioned as drivers for discriminatory treatment. COVID-19 related health system policies such as visitor restrictions and telehealth follow-ups inadvertently resulted in discriminatory practices towards BIPOC patients and patients with disabilities. As patients experience lower quality healthcare during the pandemic, COVID-19-related restrictions and policies compounded existing inequitable care for these populations. CHWS Journal Article
Woodward KF, Kett PM, Willgerodt M, Summerside N, Hart J, Buchanan DT, Cunitz TC, Birkey C, Zierler BK	Using an academic-practice partnership to enhance ambulatory care nursing skills	Nurse Education Today	12-01-2022	URL	N/A	Ambulatory nursing services are essential to healthcare in communities, but nursing curricula often omit ambulatory care training. The purpose of this project was to enhance ambulatory care competencies among nursing students and provide ongoing education for practicing nurses through an academic-practice partnership. CHWS Journal Article Nursing
Prusynski RA, Humbert A, Leland NE, Frogner BK, Saliba D, Mroz TM	Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities	Journal of the American Geriatrics Society	12-26-2022	URL	N/A	Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. CHWS CHWS Home COVID-19 Journal Article
Frogner BK	Patients Receive Flexible And Accessible Care When State Workforce Barriers Are Removed	Heath Affairs	08-30-2022	URL	N/A	In response to COVID-19, many states increased their supply of health care workers, using emergency policies to remove barriers such as state licensure requirements. The experience in New Jersey suggests that most health care workers who obtained a temporary license, including physicians, nurses, and mental health providers, provided care for existing patients for COVID-19- and non-COVID-19-related conditions, mostly through telehealth. State variation in licensure requirements, as well as scope of practice, may be a barrier to patients having flexible, accessible, and continuous care. As states emerge from the pandemic, emergency policies that expand health workforce supply by removing these state-level barriers should be made permanent. CHWS COVID-19 Journal Article
Frogner BK	The Link Between Sick Leave Laws and Emergency Department Visits	Tradeoffs	08-30-2022	URL	N/A
Nasseh K, Frogner BK, Vujicic M	A closer look at disparities in earnings between white and minoritized dentists	Health Services Research	10-28-2022	URL	N/A	To examine the factors that account for differences in dentist earnings between White and minoritized dentists. CHWS CHWS Home Journal Article
van Eijk MS, Prueher L, Kett PM, Frogner BK, Guenther GA	Financial Instability of Federal Navigator Program Challenges Organizations to Help Uninsured Enroll in Health Insurance Coverage	Journal of Health Care for the Poor and Underserved	08-01-2022	URL	The Role of Insurance Navigators in Mitigating the Financial and Health Risk of Unemployed Workers	Under the Affordable Care Act, the federal Health Insurance Navigator Program aims to reduce the rate of uninsured in the United States. Under this program, navigators help people obtain insurance coverage through federally facilitated Marketplaces. However, the program’s financial instability and substantial budget cuts created a severe shortage of navigator assistance for the uninsured and underserved. The COVID-19 pandemic added further pressure to the already-strained program. Our study examined how unstable and unpredictable federal funding and the COVID-19 pandemic affected organizations’ navigator work in the federal program in 2020. The results study show (1) that navigator organizations provide vital, year-round resources; (2) that organizations feel pushed to direct scarce resources to grant management and cut service provision; and (3) that there are policy changes that can support navigator organizations in the future. Increased and ongoing federal investment is needed to support this vital health workforce and expand enrollment assistance for underserved communities. CHWS Journal Article
Ornelas IJ, Schwartz M, Sabin JA, Frogner BK	Using Experiential Education in Health Professions Training to Improve Health Equity: Lessons Learned from Interviews With Key Informants	Journal of Higher Education Outreach and Engagement	12-15-2022	URL	Best Practices in Experiential Education to Educate Health Professionals on Heath Equity	Health professions students can increase their understanding of how social determinants impact health equity through experiential learning opportunities. Using key informant interviews with faculty and staff familiar with experiential education programs in medicine, dentistry, nursing, pharmacy, public health, and social work, we sought to identify key features and best practices to inform the broader implementation of these programs. Interviews were recorded and compiled notes were reviewed to identify common themes across programs. Experiential learning helped teach students competencies related to health equity. However, many programs were challenged by limited infrastructure and the need for faculty training on health equity topics. Key informants noted that programs should be linked to accreditation and curricular requirements. Strong community partnerships also facilitated successful program implementation. Our findings can help guide other schools considering experiential learning programs, as well as future research in this area. CHWS CHWS Home Journal Article Other
Skillman SM, Dunlap B	Washington State’s Behavioral Health Workforce: Examination of Education and Training Needs and Priorities for Future Assessment	Center for Health Workforce Studies, University of Washington	07-01-2022	Full Report	Health Workforce Sentinel Network	Objectives of this examination include: 1. Understanding the range of education and training backgrounds of the behavioral health workforce in various settings in Washington, and which positions are the most difficult to fill; 2. Identifying how the education and training preparation of behavioral health occupations meet the needs of employers and clients, and areas that could be improved; 3. Discussing barriers and facilitators in policy and practice which may assist or impede workforce training and education for Washington’s behavioral health workforce. To meet these objectives, we spoke with individuals who held roles as behavioral health care employers, clinicians, educators, and from policy and practice organizations (key informants) about the critical needs of the workforce, especially those related to the education and training preparation of the workforce as well as strategies to address them. This assessment is intended to provide information to help formulate future activities and recommendations for policy and practice to strengthen Washington’s behavioral health workforce. Allied Health CHWS Mental Health Nursing Physicians Reports and Briefs Washington
van Eijk MS, Frogner BK	How are Health Care Workers Utilized in Health Equity Interventions? An Exploratory Review	Center for Health Workforce Studies, University of Washington	09-29-2022	Full Report	Health Workforce in Health Equity Research: Who, What, When, Where, and How	Health care workers play crucial roles in interventions and policies that promote health equity by providing culturally sensitive services, partnering with communities to promote population health, and addressing unconscious racial and ethnic biases in health care delivery. Despite their significance for eliminating health disparities experienced by historically marginalized communities, the roles that the health workforce plays within these interventions are not systemically monitored. In this study, we sought to understand how health care workers are expected to address issues of health equity in a burgeoning literature by answering the following questions: 1) Which health care workers have been charged with reducing health disparities? 2) Where are they positioned in the pathway toward improving health equity? 3) What training, if any, did they receive to address health equity? Allied Health CHWS CHWS Home Complete HRSA News Reports and Briefs
Guenther G, Kett P, Skillman SM, Frogner BK	The Birth Doula Workforce in the U.S.: Rapid Response Brief	Center for Health Workforce Studies, University of Washington	08-22-2022	Rapid Response Brief	Increasing Access to Doulas to Support a Diverse Population	Over the past couple of years, there has been an increased focus in both research and policy on the role of birth doulas as an intervention to address structural inequities in the US health care system and reduce health care disparities. In response to this interest in doula services, there has been multiple state bills to expand Medicaid coverage to pay for doula services. This rapid response brief provides an overview of research on the birth doula workforce that has been published since January 2021, including workforce challenges and the effect of the COVID-19 pandemic on doulas. We discuss the available data to study the doula workforce. We begin with a brief overview of the doula workforce for which literature has been emerging. We will also highlight opportunities and research needs to support the doula workforce in the US. CHWS CHWS Home COVID-19 Other
Kett P, Skillman SM, Frogner BK	The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Workforce: Rapid Response Brief	Center for Health Workforce Studies, University of Washington	08-22-2022	Rapid Response Brief	N/A	Home visiting—a service delivery model provided to families in their home or location of choice—is considered a cost-effective approach for providing needed services and supports and has been shown to have positive short- and long-term infant, child, and family outcomes. The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program supports evidence-based home visiting with the goal of improving outcomes for at-risk pregnant people, infants, children, and families. The focus of this rapid response brief is research published since March 2020 focused on the MIECHV and the broader home visiting workforce, the effect of the COVID-19 pandemic on this workforce, and available data. We begin with a brief overview of the MIECHV program to provide context for the recent research. We also highlight the complexities in summarizing or doing research on the workforce delivering programs supported by this funding, and discuss the opportunities, challenges, and future research needs related to this workforce. Access to Care CHWS CHWS Home Complete Other
Skillman SM, Johnson HM, Frogner BK	Pathways to Registered Nursing: Influences of Health-Related Work Experience and Education Financing	Policy, Politics, & Nursing Practice	08-22-2022	URL	What are Career Pathways to Registered Nursing?	A larger and more diverse registered nurse (RN) workforce in the U.S. is needed to meet growing demand and address social determinants of health and improve health equity. To improve understanding of pathways and barriers to becoming an RN, this study examined prior health care employment and financial assistance factors associated with completion of pre-licensure RN education programs, by initial entry degree (associate degree or bachelor of science in nursing) and across racial and ethnic groups, using the 2018 National Sample Survey of Registered Nurses. The study found higher percentages of associate degree-entry RNs held a health-related job prior to completing their initial RN program than did bachelor’s degree entrants. Employer support for education financing as well as reliance on loans and scholarships increased among RNs graduating in 2000 and later, and reliance on self-financing was reported less frequently. Hispanic associate degree-entry RNs reported education financing from only federal loans more frequently compared with White RNs, and higher percentages of Black, multiracial, and “some other race” baccalaureate degree entry RNs accessed federal loans compared with White baccalaureate degree-entry RNs. These findings indicate diversifying the RN workforce should remain a priority to increase representation by underrepresented racial and ethnic groups. Equitable pathways into the RN profession will be facilitated and expedited through policies that overcome financial and social barriers that enable individuals from population groups underrepresented in the nursing workforce to identify with the RN role and route to the profession. CHWS CHWS Home Complete Journal Article Nursing
Van Eijk E, Guenther GA, Jopson AD, Skillman SM, Frogner BK	Health workforce challenges impact the development of robust doula services for underserved populations in the United States	The Journal of Perinatal Education	07-31-2022	URL	Increasing Access to Doulas to Support a Diverse Population	Evidence of doulas’ positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations’ barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities. Access to Care CHWS CHWS Home Complete Journal Article News
Frogner BK	Patients Receive Flexible And Accessible Care When State Workforce Barriers Are Removed	Health Affairs	08-01-2022	URL	N/A	In response to COVID-19, many states increased their supply of health care workers, using emergency policies to remove barriers such as state licensure requirements. The experience in New Jersey suggests that most health care workers who obtained a temporary license, including physicians, nurses, and mental health providers, provided care for existing patients for COVID-19- and non-COVID-19-related conditions, mostly through telehealth. State variation in licensure requirements, as well as scope of practice, may be a barrier to patients having flexible, accessible, and continuous care. As states emerge from the pandemic, emergency policies that expand health workforce supply by removing these state-level barriers should be made permanent. Access to Care CHWS CHWS Home COVID-19 Journal Article Mental Health News Nursing Physicians
Dahal A, Skillman SM	Washington State’s Physician Workforce in 2021	Center for Health Workforce Studies, University of Washington	07-31-2022	Full Report	Washington State’s Physician Workforce	In 2021 the estimated number of physicians providing direct patient care in Washington was 17,736, approximately 15% higher than the estimated number practicing in 2014. There were an estimated 228 physicians per 100,000 population providing direct patient care in Washington State in 2021, including 81 primary care physicians per 100,000 population. The mean age of Washington’s practicing physicians was 52 years. Women comprised 41% of the state’s physician workforce and 52% of the primary care, including 68% of general pediatricians. Compared with urban areas, most rural areas of Washington had fewer physicians per 100,000 population and many rural counties had high percentages of physicians age 55 or older. CHWS CHWS Home News Physicians Reports and Briefs Washington
Dahal A, Skillman SM	Montana’s Physician Workforce in 2021	Center for Health Workforce Studies, University of Washington,	07-31-2022	Full Report	Montana Physician Workforce	In 2021 the estimated number of physicians providing direct patient care in Montana was 2,569, 26% higher than the estimated number practicing in 2014. There were an estimated 238 physicians per 100,000 population providing direct patient care in Montana, including 83 primary care physicians per 100,000 population in 2021. The mean age of Montana’s practicing physicians was 53 years. Women comprised 34% of the state’s physician workforce and 46% of the primary care, including 68% of general pediatricians. Compared with urban areas, most rural areas of Montana had fewer physicians per 100,000 population and many rural counties had high percentages of physicians age 55 or older. CHWS CHWS Home Montana Physicians Reports and Briefs
Dahal A, Skillman SM	Wyoming’s Physician Workforce in 2021	Center for Health Workforce Studies, University of Washington	07-31-2022	Full Report	Wyoming’s Physician Workforce	In 2021 the estimated number of physicians providing direct patient care in Wyoming was 1,043, 7% higher than the estimated number practicing in 2014. There were an estimated 180 physicians per 100,000 population providing direct patient care in Wyoming, including 65 primary care physicians per 100,000 population in 2021. The mean age of Wyoming’s practicing physicians was 53 years. Women comprised 26% of the state’s physician workforce and 38% of the primary care, including 49% of general pediatricians. Most rural areas of Wyoming had fewer physicians per 100,000 population and many rural counties had high percentages of physicians age 55 or older than in urban areas. CHWS CHWS Home News Physicians Reports and Briefs Wyoming
Dahal A, Skillman SM	Alaska’s Physician Workforce in 2021	Center for Health Workforce Studies, University of Washington,	07-31-2022	Full Report	Alaska’s Physician Workforce	In 2021 the estimated number of physicians providing direct patient care in Alaska was 1,751, 19% higher than the estimated number practicing in 2014. There were an estimated 240 physicians per 100,000 population providing direct patient care in Alaska, including 95 primary care physicians per 100,000 population in 2021. The mean age of Alaska’s practicing physicians was 52 years. Women comprised 41% of the state’s physician workforce with 54% of the primary care, including 65% of general pediatricians. Compared with urban areas, most rural areas of Alaska had fewer physicians and many rural counties had high percentages of physicians age 55 or older. Around 27% of Alaska’s family medicine physician workforce completed a residency in Alaska and 41% completed a residency in one of the WWAMI states: Washington, Wyoming, Alaska, Montana or Idaho. Alaska CHWS CHWS Home News Physicians Reports and Briefs
Dahal A, Skillman SM	Idaho’s Physician Workforce in 2021	Center for Health Workforce Studies, University of Washington	07-31-2022	Full Report	Idaho’s Physician Workforce	In 2021 the estimated number of physicians providing direct patient care in Idaho was 3,180, 19% higher than the estimated number practicing in 2014. In 2021, there were an estimated 174 physicians per 100,000 population providing direct patient care in Idaho, including 64 primary care physicians per 100,000 population. The mean age of Idaho’s practicing physicians was 52 years. Women comprised 28% of the state’s physician workforce but 37% of the primary care, including about 45% of general pediatricians. Compared with urban areas, most rural areas of Idaho had fewer physicians per 100,000 population and many rural counties had higher percentages of physicians age 55 or older. CHWS CHWS Home Idaho Physicians Reports and Briefs
Oster NV, Skillman SM, Frogner BK	Health Workforce Issues in American Indian and Alaska Native (AI/AN) Populations	Center for Health Workforce Studies, University of Washington	07-01-2022	Rapid Response Brief	N/A	In this rapid response policy brief we provide an overview of the IHS, discuss tribally operated health services, and access to health services and insurance outside of tribal or IHS networks. Understanding how AI/AN populations obtain care is important to identify the health workforce that may serve the AI/AN community. We also describe the representation of AI/AN populations within the health care workforce. We highlight recommendations and strategies identified to strengthen the health workforce providing care for AI/AN populations based on the limited public information available on the IHS workforce and workforce-specific studies on AI/AN population needs. CHWS HRSA Reports and Briefs
Kett PM, van Eijk MS, Guenther GA, Skillman SM	"This work that we're doing is bigger than ourselves": A qualitative study with community-based doulas in the United States	Perspectives on Sexual and Reproductive Health	07-07-2022	URL	Doula Project 2.0: Increasing the Use of Doulas by Underserved Communities	Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided are needed to strengthen and sustain this critical part of the perinatal workforce. Allied Health CHWS HRSA In-Progress Journal Article
Kett PM, Bekemeier B, Altman MR, Herting JR	‘Not Everybody Approaches It that Way’: Nurse-Trained Health Department Directors’ Leadership Strategies and Skills in Public Health	Nursing Inquiry	03-09-2022	URL	N/A	Evidence points to nurses as possessing particular skills which are important for public health leadership; in particular, investigators have found that a nurse public health director is strongly associated with positive health department performance. To better understand this association and to guide the effective deployment of nurse leaders, researchers sought to explore the specific leadership strategies used by nurse public health directors, using a critical thematic analysis approach to examine these leadership strategies in the context of certain ideologies, power differentials, and social hierarchies. Data were collected via semistructured interviews conducted from July to September 2020 with 13 nurse public health directors from across the United States. Major themes illustrate a distinct picture of the nursing approach to public health leadership: (a) approaching their work with an other-focused lens, (b) applying theoretical knowledge, (c) navigating the political side of their role, and (d) leveraging their nursing identity. Findings articulate the nurse public health director’s distinctive combination of skills which reflect the interprofessional nature of public health nursing practice. Such skills demonstrate a specialized approach that may set nurse leaders apart from other types of leaders in carrying out significant public health work.
Jopson AD, Cummings AG, Frogner BK, Skillman SM	Employers’ perspectives on the use of medical assistant apprenticeships: a qualitative study	J Ambul Care Manag	07-01-2022	URL	Apprenticeships as Pathways to Healthcare Careers: Experiences of Employers Using Medical Assistant Apprenticeships	Medical assistants (MAs) are among the fastest-growing occupations in the United States, yet health care employers report high turnover rates and difficulty filling MA positions. Employers are increasingly using apprenticeship to meet emerging workforce needs. This qualitative study examined the perspectives of 14 employers using registered MA apprenticeships in 8 states. The findings revealed motivations for using apprenticeship, perceived benefits to the organization, challenges with implementation, and reflections on successful implementation. We detail how MA apprenticeship is successfully meeting recruitment and training needs in a variety of health care organizations, especially where program support resources are available. Access to Care Allied Health CHWS CHWS Home Health Care Outcomes and Quality HWRC In-Progress Journal Article Other Work Settings Washington
Harwood KJ, Pines J, Andrilla CH, Frogner BK	Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US.	BMC Health Services Research	05-01-2022	URL	The Effects of Timing of Physical Therapy on Health Care Costs, Utilization, and Opioid Use
Dill J, Frogner BK, Travers J	Taking the long view: understanding the rate of second job holding among long-term care workers	Med Care Res Rev	04-25-2022	URL	N/A
Frogner BK, Dill J	Tracking turnover among health care workers during the COVID-19 pandemic	JAMA Health Forum	05-01-2022	URL	Where and From What Industries are Health Care Workers Entering Health Care Jobs and Where are We Losing Them During COVID-19?	Abstract Importance The health care sector lost millions of workers during the COVID-19 pandemic and job recovery has been slow, particularly in long-term care. Objective To identify which health care workers were at highest risk of exiting the health care workforce during the COVID-19 pandemic. Design, Setting, and Participants This was an observational cross-sectional study conducted among individuals employed full-time in health care jobs from 2019 to 2021 in the US. Using the data from the Current Population Survey (CPS), we compared turnover rates before the pandemic (preperiod, January 2019-March 2020; 71 843 observations from CPS) with the first 9 months (postperiod 1, April 2020-December 2020; 38 556 observations) and latter 8 months of the pandemic (postperiod 2, January 2021-October 2021; 44 389 observations). Main Outcomes and Measures Health care workforce exits (also referred to as turnover) defined as a health care worker’s response to the CPS as being unemployed or out of the labor force in a month subsequent to a month when they reported being actively employed in the health care workforce. The probability of exiting the health care workforce was estimated using a logistic regression model controlling for health care occupation, health care setting, being female, having a child younger than 5 years old in the household, race and ethnicity, age and age squared, citizenship status, being married, having less than a bachelor’s degree, living in a metropolitan area, identifier for those reporting employment status at the first peak of COVID-19, and select interaction terms with time periods (postperiods 1 and 2). Data analyses were conducted from March 1, 2021, to January 31, 2022. Results The study population comprised 125 717 unique health care workers with a mean (SD) age of 42.3 (12.1) years; 96 802 (77.0%) were women; 84 733 (67.4%) were White individuals. Estimated health care turnover rates peaked in postperiod 1, but largely recovered by postperiod 2, except for among long-term care workers and physicians. We found a 4-fold difference in turnover rates between physicians and health aides or assistants. Rates were also higher for health workers with young children (<5 years), for both sexes and highest among women. By race and ethnicity, persistently higher turnover rates were found among American Indian/Alaska Native/Pacific Islander workers; White workers had persistently lower rates; and Black and Latino workers experienced the slowest job recovery rates. Conclusions and Relevance The findings of this observational cross-sectional study suggest that although much of the health care workforce is on track to recover to prepandemic turnover rates, these rates have been persistently high and slow to recover among long-term care workers, health aides and assistants, workers of minoritized racial and ethnic groups, and women with young children. Given the high demand for long-term care workers, targeted attention is needed to recruit job-seeking health care workers and to retain those currently in these jobs to lessen turnover. Allied Health CHWS
Oster NV, Patterson DG, Skillman SM, Frogner BK	COVID-19 and the Rural Health Workforce: The Impact of Federal Pandemic Funding to Address Workforce Needs	Center for Health Workforce Studies, University of Washington	03-01-2022	Policy Brief	What is Being Done to Prepare the Rural Health Workforce for COVID-19?	In this report we describe the workforce challenges faced by rural health care delivery systems and discuss how pre-pandemic financial instability in rural health care facilities may have contributed to the challenges experienced by the rural health workforce during the pandemic. We also discuss the availability of federal pandemic funding to address rural health workforce needs, the ability of rural facilities to access and utilize the funding, and the long-term needs of the rural health workforce and delivery system. Allied Health CHWS CHWS Home Complete COVID-19 Hospitals HRSA National News Reports and Briefs
Pines JM, Harwood K, Andrilla CHA, Frogner BK	Opioid Prescriptions, Radiography, and Costs for Self-Limited “One-and- Done” Lower Back Pain Visits in a Commercially Insured Population	Center for Health Workforce Studies, University of Washington	03-01-2022	Findings Brief	The Effects of Timing of Physical Therapy on Health Care Costs, Utilization, and Opioid Use	In this study, we explore a large sample of commercial beneficiaries with a single encounter with a clinician without further visits, termed “one-and-done” low back pain visits. The purpose was to examine the frequency of one-and-done low back pain patient visits across different clinician types in a commercial insured population, and compare imaging, opioid prescription rates, and costs across clinician types. Allied Health CHWS CHWS Home Complete Reports and Briefs
Van Eijk MS, Guenther GA, Kett PM, Jopson AD, Frogner BK, Skillman SM	Addressing systemic racism in birth doula services to reduce health inequities in the United States	Health Equity	02-02-2022	URL	Increasing Access to Doulas to Support a Diverse Population	Birth doulas support pregnant people during the perinatal period. Evidence of doulas’ positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services. Journal Article
van Eijk MS, Kett PM, Prueher L, Frogner BK, Guenther GA	Lack of Consistent Investment in Federal Insurance Navigator Program Undermines Navigators' Equity Work in Vulnerable Communities	J Public Health Manag Pract	07-30-2022	URL	The Role of Insurance Navigators in Mitigating the Financial and Health Risk of Unemployed Workers	Navigators in the federal Insurance Navigator Program (“Navigator Program”), who are employed by organizations in states with Federally Facilitated Marketplaces, provide enrollment assistance, outreach, and education to individuals who are eligible for health insurance coverage. Such work is central to public health efforts to address inequities but continues to be poorly understood and undervalued. More information is needed to understand the components of navigators’ equity work and how decreases in program funding have affected their service provision. CHWS Journal Article
Patterson DG, Stubbs BA, Nudell NG	How Actual Practice of Emergency Medical Services Personnel Aligns with the Recommended National Scope of Practice in Rural Versus Urban Areas of the U.S.	Center for Health Workforce Studies, University of Washington	02-17-2022	Full Report	Scope of Practice Alignment of Emergency Medical Services Personnel	The 2019 National EMS Scope of Practice Model provides recommended guidelines for states to develop scopes of practice for emergency medical services (EMS) practitioners. This study had two main aims: (1) examine the extent to which EMS professionals perform skills that correspond to their credential levels as described in the national Model and (2) determine whether there are variations in adherence to Model guidelines between agencies serving rural versus urban populations and agencies with unpaid (volunteer) versus paid staffing models. CHWS Reports and Briefs
Sabin J, Guenther G, Ornelas IJ, Patterson DG, Andrilla C, Morales L, Gurjal K, Frogner BK	Brief online implicit bias education increases bias awareness among clinical teaching faculty	Med Educ Online (Open Access)	12-27-2021	URL	Implicit Race and Gender Bias, Bias Awareness, and Impact of a Course for Clinical Faculty	Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness. CHWS Journal Article
Frogner BK	How the Health Services Research Workforce Supply in the United States is Evolving	Health Services Research	01-04-2022	URL	N/A	Objective To investigate how the health services research (HSR) workforce supply in the United States has evolved over the last five years. Data Sources Membership data of AcademyHealth participants, professional networking websites, PubMed, grant databases, and the Integrated Post secondary Education Data System. Study Design Descriptive study comparing size and characteristics of the HSR workforce and graduates identified across multiple data sources. Lists of authors and principal investigators (PIs) were merged and de-duplicated to identify unique counts. Pearson’s Chi Squared test was used to compare characteristics between members and non-members of AcademyHealth. CHWS National
Jopson AD, Frogner BK	An Examination of Health Care Workers in Nonstandard Work Arrangements and Self-Employment	Center for Health Workforce Studies, University of Washington	11-01-2021	Full Report	Allied Health Professionals and the “Gig Economy”: Trends in Alternative Work Arrangements	This study used data from the Contingent Worker Supplement (CWS) to the Current Population Survey (CPS) that was fielded in May 2017 by the US Census Bureau for the BLS. Using BLS definitions, we examined health care workers across three work arrangements: 1) self-employment, 2) contingent work, and 3) alternative work. Allied Health CHWS CHWS Home Complete HRSA National News Nursing Physicians
Dahal A, Stubbs BA, Frogner BK, Skillman SM	Leveraging Data to Monitor the Allied Health Workforce: State Supply Estimates	Center for Health Workforce Studies, University of Washington	11-01-2021	Full Report	Phase II of Leveraging Data for Allied Health Occupations	Securing up-to-date and accurate data on the number of the health care workers is crucial for health workforce planning. This study developed and compared national and state estimates of the supply of allied health occupations drawn from two publicly available national data sources (the American Community Survey [ACS] and the Occupational Employment and Wage Statistics [OEWS] from 2014 and 2017]), and from state license records (2016-17), expanding on the 2015-2016 UW CHWS study “Data for Allied Health Workforce Research.” The final report for this Phase II study describes uses and limitations of workforce supply estimates from the data sources examined. Allied Health CHWS CHWS Home Complete HRSA News Reports and Briefs
Dunlap B, Basye A, Skillman SM.	Background Checks and the Health Workforce: Practices, Policies and Equity	Center for Health Workforce Studies, University of Washington	11-01-2021	Full Report	Criminal Background Checks and Drug Testing in Health Workforce Employment: Implications for Health Equity?	Background checks are intended to prevent harms to clients and businesses and ensure a quality workforce, but they may also exclude qualified workers. This study examined why and how background checks are used; the broad variation of laws, regulations and policies that govern them; evidence relevant to their use and potential misuse; and ways to use background checks to help ensure patient/client safety while supporting health workforce development. Allied Health CHWS CHWS Home Complete HRSA News Reports and Briefs Washington
Frogner BK	How Do You Create a “Zero-Burnout” Primary Care Practice?	Tradeoffs.org Newsletter	07-02-2021	URL	N/A	Burnout among primary care providers (PCPs) has long been a concern in medicine. PCPs are often paid less than other specialists, have to deal with enormous amounts of administrative tasks that take away from patient time, and often (though increasingly rarely) own their own practices, adding the burdens and stresses of a small business owner. COVID-19 unsurprisingly exacerbated these stressors, and even as cases decrease, an ongoing survey of PCPs finds high levels of stress and burnout combined with workforce and workload challenges well over a year into the pandemic. There may be long-term consequences for clinician recruitment and retention and ultimately patient care if we do not have a robust health workforce. CHWS Other
Kett PM, Bekemeier B, Herting JR, Altman MR	Addressing Health Disparities: The Health Department Nurse Lead Executive's Relationship to Improved Community Health	Journal of Public Health Management and Practice	09-01-2021	URL	N/A	The nurse-trained local health department (LHD) lead executive has been shown to be positively associated with LHD performance; however, no other research has explored whether this association translates to improved community health. CHWS Journal Article
Beck AJ, Spetz J, Pittman P, Frogner BK, Fraher EP, Moore J, Armstrong D, Buerhaus PI	Investing In A 21st Century Health Workforce: A Call For Accountability	Health Affairs Blog	09-15-2021	URL	N/A	The US health workforce is receiving a massive boost in federal investment under the $1.9 trillion American Rescue Plan Act of 2021. Included provisions will allow states to receive higher federal matching funds through Medicaid, adding approximately $12.7 billion over the next year to strengthen the workforce for home- and community-based services; rural health providers will see an additional $8.5 billion in Provider Relief Fund dollars; more than $7.0 billion will be invested to expand, train, and retain the public health workforce; $1.55 billion will be allocated to expand critical programs that strengthen the workforce in underserved communities and address unmet health care needs; and nearly $250.0 million will be used to strengthen behavioral health workforce capacity. This infusion of health workforce investments comes on the heels of substantial provider support already allocated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and is likely to be followed by additional investments under the infrastructure plan proposed by President Joe Biden. Journal Article
Armstrong D, Moore J, Fraher EP, Frogner BK, Pittman P, Spetz J	COVID-19 and the Health Workforce	Medical Care Research and Review	10-30-2020	URL	N/A	The health workforce has been greatly affected by COVID-19. In this commentary, we describe the articles included in this health workforce research supplement and how the issues raised by the authors relate to the COVID-19 pandemic and rapidly changing health care environment. CHWS Journal Article
Frogner BK, Schwartz M	Examining Wage Disparities by Race and Ethnicity of Health Care Workers	Medical Care	10-01-2021	URL	Examining Wage Disparities by Race and Ethnicity of Healthcare Workers	Prior studies demonstrated that wage disparities exist across race and ethnicity within selected health care occupations. Wage disparities may negatively affect the industry’s ability to recruit and retain a diverse workforce throughout the career ladder. CHWS Journal Article Other
Dahal A, Frogner BK, Skillman SM, Patterson DG	Accelerating Health Professions Pathways for Immigrants	Center for Health Workforce Studies, University of Washington	07-26-2021	Full Report	Accelerated Pathways for Internationally Educated Health Professionals
Prusynski R, Frogner BK, Skillman SM, Dahal A, Mroz TM	Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities	Journal of Applied Gerontology	07-22-2021	URL	Supply of and Demand for Therapy Services in Skilled Nursing Facilities
Prusynski R, Frogner BK, Dahal A, Skillman SM, Mroz T	Skilled Nursing Facility Characteristics Associated with Financially Motivated Therapy and Relation to Quality	Journal of the American Medical Directors Association	06-06-2020		Supply of and Demand for Therapy Services in Skilled Nursing Facilities
Oster NV, Guenther G, Frogner BK, Skillman SM	The Clinical Laboratory Workforce in the U.S.: Supply, Distribution, Education Pathways, and State Responses to the COVID-19 Emergency	Center for Health Workforce Studies, University of Washington	06-14-2021	Policy Brief	How are Allied Health Workers Being Deployed During COVID-19?
Oster NV, Skillman SM, Frogner BK	COVID-19’s Effect on the Employment Status of Health Care Workers	Center for Health Workforce Studies, University of Washington	05-26-2021	Policy Brief	What Types of Changes in Employment Status Have Been Most Common Among Health Care Workers as a Result of the COVID-19 Emergency?	The COVID-19 pandemic has had a dynamic effect on the health workforce. Redeployment, furlough, and layoff are among the terms used to describe various work statuses. Some terms are related and overlapping, potentially causing confusion for employees, media, policymakers, and researchers who may be interested in tracking health care employment trends throughout the pandemic. In this report, we define the range of work statuses that one can hold and identify areas where overlap in terms may create confusion. We describe how work status relates to employees’ wages and/or benefits as well as eligibility for unemployment benefits. We examine how self-employed health care workers and those not currently in the labor force fit into ongoing employment discussions during the COVID-19 pandemic. In closing, we discuss the potential long-term impacts of the COVID-19 pandemic on employment in the health care industry. Access to Care Allied Health CHWS CHWS Home COVID-19 Hospitals National Reports and Briefs
Prusynski R, Leland N, Frogner BK, Leibbrand C, Mroz TM	Therapy Staffing in Skilled Nursing Facilities Declined After Implementation of the Patient Driven Payment Model	JAMDA	05-06-2021	URL	Supply of and Demand for Therapy Services in Skilled Nursing Facilities	Objective The Patient Driven Payment Model (PDPM), a new reimbursement policy for Skilled Nursing Facilities (SNFs), was implemented in October 2019. PDPM disincentivizes provision of intensive physical and occupational therapy, however, there is concern that declines in therapy staffing may negatively impact patient outcomes. This study aimed to characterize the SNF industry response to PDPM in terms of therapy staffing. Design Segmented regression interrupted time series. Setting and Participants 15,432 SNFs in the United States. Methods Using SNF Payroll Based Journal data from January 1, 2019, through March 31, 2020, we calculated national weekly averages of therapy staffing minutes per patient-day for all therapy staff and for subgroups of physical and occupational therapists, therapy assistants, contract staff, and in-house employees. We used interrupted time series regression to estimate immediate and gradual effects of PDPM implementation. Results Total therapy staffing minutes per patient-day declined by 5.5% in the week immediately following PDPM implementation (P < .001), and the trend experienced an additional decline of 0.2% per week for the first 6 months after PDPM compared with the negative pre-PDPM baseline trend (P < .001), for a 14.7% total decline by the end of March 2020. Physical and occupational therapy disciplines experienced similar immediate and gradual declines in staffing. Assistant and contract staffing reductions were larger than for therapist and in-house employees, respectively. All subgroups except for assistants and contract staff experienced significantly steeper declines in staffing trends compared with pre-PDPM trends. Conclusions and Implications SNFs appeared to have responded to PDPM with both immediate and gradual reductions in therapy staffing, with an average decline of 80 therapy staffing minutes over the average patient stay. Assistant and contract staff experienced the largest immediate declines. Therapy staffing and quality outcomes require ongoing monitoring to ensure staffing reductions do not have negative implications for patients. CHWS Journal Article
Garcia E, Kundu I, Kelly M, Guenther G, Skillman SM, Frogner B	The Clinical Laboratory Workforce: Understanding the Challenges to Meeting Current and Future Needs	American Society for Clinical Pathology (Washington, DC) and Center for Health Workforce Studies, University of Washington (Seattle, WA)	04-01-2021	Full Report	Identifying the Barriers and Facilitators to Strengthen the Clinical Lab Professional Workforce	Laboratory medicine is a critical component of the complex U.S. healthcare system, providing patients and medical providers with information essential for the prevention, diagnosis, treatment, and management of health and disease. The clinical laboratory workforce (also referred to as the medical laboratory workforce) supports a laboratory system that provides a variety of objective information used in clinical decision making. The laboratory workforce is diverse in terms of their roles, the types of tasks they perform, the types of qualifications needed, and the level of educational experience required to enter the field. However, many of them share common challenges facing the current and future state of the field, such as a declining number of accredited education programs and resulting decline in the number of students entering these programs, shortages of qualified personnel, increased demands on the workforce, and unmet employer demand. More information about factors contributing to these challenges is needed. CHWS Reports and Briefs
Mohammed SA, Guenther GA, Frogner BK, Skillman SM	Examining the Racial and Ethnic Diversity of Associate Degree in Nursing Programs by Type of Institution in the US, 2012–2018	Nursing Outlook	07-01-2021	URL	Racial/Ethnic Diversity in Associate Degree Programs in Nursing	Abstract Background Increasing nursing workforce diversity is essential to quality health care. Associate Degree in Nursing (ADN) programs are a primary path to becoming a registered nurse and an important source of nursing diversity. Purpose To examine how the number of graduates and racial/ethnic student composition of ADN programs have changed since the Institute of Medicine’s recommendation to increase the percentage of bachelor’s-prepared nurses to 80%. Methods Using data from the Integrated Postsecondary Education System, we analyzed the number of graduates and racial/ethnic composition of ADN programs across public, private not-for-profit, and private for-profit institutions, and financial aid awarded by type of institution from 2012-2018. Discussion Racial/ethnic diversity among ADN programs grew from 2012-2018. Although private for-profits proportionally demonstrated greater ADN student diversity and provided financial aid institutionally to a higher percentage of students, public schools contributed the most to the number and racial/ethnic diversity of ADN graduates. Conclusion Given concerns regarding private for-profits, promoting public institutions may be the most effective strategy to enhance diversity among ADN nurses. CHWS Journal Article
Frogner BK	One Change That Could Help Nursing Homes Recover from COVID-19 Fears and Become Safer Places for Aging Parents	The Conversation	04-13-2021	URL	N/A
Frogner BK, Skillman SM	Op-Ed: It's Time to Address Staffing at Nursing Homes — The Elephant in the Room	MedPage Today	12-07-2020	URL	N/A
O’Connor JG, Dunlap B, Gattman NE, Skillman SM	Washington’s Behavioral Health Workforce: Barriers and Solutions. Phase II Report and Recommendations	Washington Workforce Board and Center for Health Workforce Studies, University of Washington	12-01-2020	Full Report	Washington State Behavioral Health Workforce Assessment 2019-2020
Oster NV, Skillman SM, Stubbs BA, Dahal A, Guenther G, Frogner BK	The Physical Therapist Workforce in the U.S.: Supply, Distribution, Education Pathways, and State Responses to the COVID -19 Emergency	Center for Health Workforce Studies, University of Washington	11-16-2020	Policy Brief	How are Allied Health Workers Being Deployed During COVID-19?	The traditional role of physical therapists is to prescribe exercises and provide hands-on care to help patients develop, maintain, and restore functional ability that may be limited by injuries, aging, and chronic or progressive diseases. Physical therapists may provide preventive care, rehabilitation, education, and treatment for those with chronic conditions including scoliosis, arthritis, obesity, amputations, and cerebral palsy. CHWS COVID-19 National Reports and Briefs
Frogner BK, Skillman SM	The Challenge in Tracking Unemployment Among Health Care Workers and Why It Matters	JAMA Health Forum	11-09-2020	URL	N/A	The health care industry lost 1.5 million jobs between March and April 2020, the height of the coronavirus disease 2019 (COVID-19) pandemic in the US. More than half a million jobs remain lost 6 months later, with losses spread across the major health care sectors of hospitals (22.7%), ambulatory care settings (39.6%), and long-term care (LTC) facilities (37.7%). The job loss in LTC facilities (eg, skilled nursing facilities, residential care, assisted living) represents 6.2% of their workforce compared with 2.8% in ambulatory care and 2.4% in hospitals. The LTC sector has seen a steady decline in employment since the start of the pandemic, while the other health care sectors have mostly rebounded. The job loss in LTC is concerning but not surprising, given reports of high COVID-19 risk and burnout. Tracking these unemployed workers is a challenge yet is necessary to develop a strategy to strengthen the LTC workforce and improve health care delivery CHWS Journal Article
Oster NV, Pollack SW, Skillman SM, Stubbs BA, Dahal A, Guenther G, Frogner BK	The Pharmacist Workforce in the U.S.: Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand	Center for Health Workforce Studies, University of Washington	09-24-2020	Full Brief	How are Allied Health Workers Being Deployed During COVID-19?
Lai AY, Skillman SM, Frogner BK	Is It Fair? How To Approach Professional Scope-Of-Practice Policy After The COVID-19 Pandemic	Health Affairs Blog	06-29-2020	URL	N/A
Pollack SW, Skillman S, Frogner BK	Assessing the Size and Scope of the Pharmacist Workforce in the U.S	Center for Health Workforce Studies, University of Washington	09-04-2020	Full Report	Assessing the Size and Scope of the Pharmacist Workforce in the US	Pharmacists are increasingly recognized as crucial members of the health care team. To date, no single source of information exists that best characterizes the increasingly complex nature of the pharmacist workforce. This study aimed to identify the many different settings where pharmacists work, their current and emerging roles, and the barriers and facilitators to greater involvement of pharmacists in patient care. We reviewed the literature and conducted interviews with key stakeholders from national pharmacy professional organizations. This study found that there is not a single, agreed upon categorization that captures the full range of pharmacists’ roles and functions. The most frequently mentioned roles for pharmacists identified from the literature and stakeholder interviews included medication dispensing, medication therapy management, chronic disease management, transition of care, and patient education, health promotion, and disease prevention. Pharmacist scope-of-practice laws and regulations vary by state with most states allowing prescriptive authority. Improving awareness of the potential roles of pharmacists would help to more effectively incorporate them into the health care team. As the pharmacist workforce expands its role in health care delivery, simultaneous changes in policies and financing are important to optimize the use of pharmacists to improve care. CHWS Reports and Briefs
Mroz TM, Dahal A, Prusynski R, Skillman S, Frogner BK	Variation in Employment of Therapy Assistants in Skilled Nursing Facilities Based on Organizational Factors	Medical Care Research and Review	08-28-2020	URL	Supply of and Demand for Therapy Services in Skilled Nursing Facilities	Employment of therapy assistants enables skilled nursing facilities to provide more therapy services at lower costs. Yet little is known about employment of therapy assistants relative to organizational characteristics. Taking advantage of publicly available Medicare administrative data from 2016, we examined the relationships between organizational characteristics of skilled nursing facilities and employment of therapy assistants. Therapy assistants represent approximately half of the therapy workforce in skilled nursing facilities. Regression analyses indicate significantly higher percentages of therapy assistants are employed in facilities that are staffed by contract therapists, provide more therapy, have more total stays, operate in rural areas, and are located in states with certificate of need laws or moratoria. Skilled nursing facility quality was not significantly associated with employment of therapy assistants. As new payment mechanisms change incentivizes for therapy in skilled nursing facilities, employment of therapy assistants may be a cost-effective way to continue to provide services when necessary. CHWS Journal Article
Stubbs BA, Skillman SM	Washington State’s 2019 Licensed Practical Nurse Workforce	Center for Health Workforce Studies, University of Washington	05-01-2020	Full Report Supplement	Washington State’s Nurse Workforce – 2019
Mroz TM, Frogner BK, Patterson DG	The Impact Of Medicare’s Rural Add-On Payments On Supply Of Home Health Agencies Serving Rural Counties	Health Affairs	06-01-2020	URL	The Impact of Medicare’s Rural Add-on Payments in Home Health on Access to Care and Home Health Markets	Intermittently since 2001, Medicare has provided a percentage increase over standard payments to home health agencies that serve rural beneficiaries. Yet the effect of rural add-on payments on the supply of home health agencies that serve rural communities is unknown. Taking advantage of the pseudo–natural experiment created by varying rural add-on payment amounts over time, we used data from Home Health Compare to examine how the payments affected the number of home health agencies serving rural counties. Our results suggest that while supply changes are similar in rural counties adjacent to urban areas and in urban counties regardless of add-on payments, only higher add-on payments (of 5 percent or 10 percent) keep supply changes in rural counties not adjacent to urban areas on pace with those in urban counties. Our findings support the recent shift from broadly applied to targeted rural add-on payments but raise questions about the effects of the amount and eventual sunset of these payments on the supply of home health agencies serving remote rural communities. CHWS Journal Article
Fraher EP, Pittman P, Frogner BK, Spetz J, Moore J, Beck AJ, Armstrong D, Buerhaus PI	Ensuring and Sustaining a Pandemic Workforce	The New England Journal of Medicine	04-08-2020	URL	N/A
Frogner BK, Fraher EP, Spetz J, Pittman P, Moore J, Beck AJ, Armstrong D, Buerhaus PI	Modernizing Scope-of-Practice Regulations — Time to Prioritize Patients	The New England Journal of Medicine	02-13-2020	URL	N/A
Dahal A, Skillman SM, Patterson DG, Frogner BK	What Commute Patterns Can Tell Us About the Supply of Allied Health Workers and Registered Nurses	Center for Health Workforce Studies, University of Washington	05-01-2020	Full Report Policy Brief	Commuting Patterns of Allied Health Workers and Registered Nurses	Information on the available supply of workers in a local job market is important when determining whether there are qualified workers to fill health care jobs in demand. The American Community Survey (ACS), a publicly available annual survey of over 3.5 million households conducted by the U.S. Census Bureau, has been a regular source of information for mapping the geographic distribution of a wide range of occupations, describing the time, duration and distance of workers’ commutes, and identifying common forms of transportation for commuting. In this study, we explore what the ACS can tell us about commuting patterns among selected allied health occupations and registered nurses (RNs) as well as how these patterns may inform discussions of health workforce supply. Allied Health CHWS CHWS Home Complete National News Nursing Reports and Briefs
Stubbs BA, Skillman SM	Washington State’s 2019 Advanced Registered Nurse Practitioner Workforce	Center for Health Workforce Studies, University of Washington	03-01-2020	Full Report Supplemental	Washington State’s Nurse Workforce – 2019	In order to better monitor health workforce changes, some states have implemented processes by which health care professionals, including ARNPs, complete workforce surveys at licensing and/or with license renewal. When data from workforce surveys are linked to licensure data, and if surveys are conducted online, data collection costs can be greatly reduced and response rates are typically higher than for separate mailed or phone-based surveys. In 2018, Washington’s Nursing Care Quality Assurance Commission (NCQAC) required that all nurses licensed in the state must provide workforce data at initial licensure and renewal through the Nursys e-Notify survey conducted by the National Council of State Boards of Nursing (NCSBN). With funding from the Washington Center for Nursing, the UW CHWS conducted analyses of these data following the first full year of mandated data collection for ARNPs, as well as for licensed practical nurses (LPNs) and registered nurses (RNs). This report describes the results of these analyses for Washington’s ARNPs. CHWS Nursing Reports and Briefs
Skillman SM, Frogner BK, Dahal A, Stubbs BA, Guenther G	The Respiratory Therapist Workforce in the U.S. Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand	Center for Health Workforce Studies, University of Washington	04-02-2020	Rapid Response Brief	Phase II of Leveraging Data for Allied Health Occupations	This Rapid Response Brief provides information about the respiratory therapist workforce in the U.S. It includes descriptions of the supply, distribution, education pathways, as well as COVID-19 emergency concerns about the respiratory therapist workforce capacity and examples of state approaches to address workforce gaps. CHWS Reports and Briefs
Stubbs BA, Skillman SM	Washington State’s 2019 Registered Nurse Workforce	Center for Health Workforce Studies, University of Washington	03-01-2020	Full Report Supplement	Washington State’s Nurse Workforce – 2019	Information about the demographic, education, and practice characteristics of the registered nurse (RN) workforce is needed to support health workforce planning in the state. In 2018, Washington’s Nursing Care Quality Assurance Commission required that all nurses licensed in the state provide workforce data through the Nursys e-Notify survey conducted by the National Council of State Boards of Nursing. This report, funded by the Washington Center for Nursing, presents findings from the University of Washington Center for Health Workforce Studies’ analyses of data from registered nurses (RNs) who had completed the survey as of May, 2019. These survey data greatly enhance and complement existing nurse workforce supply information from sources such as the state’s health professional licensing files and the occasional sample surveys that have focused on aspects the state’s RN workforce. Findings from the Nursys e-Notify survey, when linked with state RN license records, provide more precise and timely information about the characteristics, distribution, qualifications and practice settings of Washington’s RN workforce. CHWS CHWS Home News Nursing Reports and Briefs Washington
LeRouge C, Sangameswaran S, Frogner BK, Snyder CR, Rubenstein L, Kirsh S, Sayre G	The Group Practice Manager in the VHA: A View From the Field	Federal Practitioner	02-01-2020	URL	N/A	The VHA created the group practice manager (GPM), a new position responsible for improving clinical practice management and unifying access improvement across leadership levels, professions, and services within each local medical system. In May 2015, the VHA began hiring and training GPMs to spearhead management of access to services. The US Department of Veterans Affairs (VA) Office of Veteran Access to Care spearheaded GPM training, including face-to-face sessions, national calls, webinars, and educational materials. Five local medical systems were selected by the VA Office of Veteran Access to Care to implement the GPM role to allow for an early evaluation of the program that would inform a subsequent nationwide rollout. Implementation of the GPM role remained in the hands of local medical systems. CHWS CHWS Home Hospitals Journal Article
Pollack SW, Skillman SM, Frogner BK	The Health Workforce Delivering Evidence-Based Non-Pharmacological Pain Management	Center for Health Workforce Studies, University of Washington	02-07-2020	Full Report Policy Brief	Role of Allied Health Professions in Treating Pain	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 health-related occupations that are 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 this workforce to effectively help manage chronic pain. Allied Health CHWS Reports and Briefs
Schwartz MR, Patterson DG, McCarty RL	State Incentive Programs that Encourage Allied Health Professionals to Provide Care for Rural and Underserved Populations	Center for Health Workforce Studies, University of Washington	12-10-2019	Full Report Policy Brief	State Incentive Programs that Encourage Allied Health Professionals to Provide Care for Underserved Populations	State-based programs that provide loans, scholarships, and other incentives for allied health professionals in exchange for service in rural and underserved areas are one approach to alleviating workforce shortages. This study examined the operation of these programs across the U.S., allied health professionals targeted, and efforts to gauge programs’ success in recruitment and retention through a review of publicly available information on state programs and interviews with program leaders in 27 states. Allied Health CHWS CHWS Home Mental Health National News Oral Health Reports and Briefs
O’Connor JG, Gattman NE, Coleman L, Dunlap B, Skillman SM	Washington’s behavioral health workforce: Barriers and solutions. Phase I	Report and Recommendations	11-01-2019	Behavioral Health Workforce Phase 1	Washington State Behavioral Health Workforce Assessment 2019-2020	Report and recommendations for the Washington Workforce Training and Education Coordinating Board CHWS CHWS Home Mental Health News Reports and Briefs Washington
Frogner BK	Interchangeability of PAs and NPs	Journal of the American Academy of Physician Assistants	12-02-2019	URL	N/A	Rod Hooker asked that Bianca Frogner reflect and add her perspective on his paper about whether NPs and PAs are interchangeable. Allied Health CHWS Journal Article Nurse Practitioner physician assistant
Larson EH, Frogner BK	Characteristics of Physician Assistant Students Planning to Work in Primary Care	J Physician Assist Educ	10-21-2019	URL Policy Brief	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 (57.3%) 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. CHWS Journal Article National
Jopson AD, Skillman SM, Frogner BK	Use of Apprenticeship to Meet Demand for Medical Assistants in the U.S	Center for Health Workforce Studies, University of Washington	09-27-2019	Policy Brief Full Report	The Role of Apprenticeships in Meeting Employers’ Demand for Allied Health Occupations	Medical assistants (MAs) are key members of the health care team and are assuming new and expanded roles amid health care delivery transformation. Some health care employers are turning to apprenticeships to meet their MA workforce needs. We conducted a literature review and semi-structured phone interviews in 2018 and early 2019 with key personnel involved with registered MA apprenticeship programs in 12 states. Interviews explored program origins, delegated responsibilities, and resources and challenges with starting and maintaining MA apprenticeship programs. Interviewees for this study identified 23 active MA apprenticeship programs and one program in development across 12 states. Programs were found in a variety of health care settings, including community health centers, school-based clinics, tribal health centers, hospital systems, and hospice care among others. Programs ranged in size from one apprentice in training per year to multiple cohorts of 20 apprentices per year. Allied Health CHWS Reports and Briefs
Dahal A, Bellows BK, Jiao T, Biskupiak J	A Cost-utility Analysis of Pregabalin vs. Duloxetine for the Treatment of Painful Diabetic Neuropathy	J Pain Palliat Care Pharmacother	06-01-2012	URL	N/A	The objective of the current study was to determine the cost-utility of pregabalin versus duloxetine for treating painful diabetic neuropathy (PDN) using a decision tree analysis. Literature searches identified clinical trials and real-world studies reporting the efficacy, tolerability, safety, adherence, opioid usage, health care utilization, and costs of pregabalin and duloxetine. The proportions of patients reported in the included studies were used to determine probabilities in the decision tree model. The base-case model included the Food and Drug Administration (FDA)-approved doses of pregabalin (300 mg/day) and duloxetine (60 mg/day), whereas “real-world” sensitivity analyses explored the effects over a range of doses (pregabalin 75-600 mg/day, duloxetine 20-120 mg/day). A 6-month time horizon and a US third-party payer perspective were chosen for the study. Outcomes from the model were expressed as cost per quality-adjusted life-year (QALY). In the base-case model, duloxetine cost less and was more effective than pregabalin (incremental cost -$187, incremental effectiveness 0.011 QALYs). Results from two real-world sensitivity analyses indicated that duloxetine cost $16,300 and $20,667 more per additional QALY than pregabalin. Using a decision tree model that incorporated both clinical trial and real-world data, duloxetine was a more cost-effective option than pregabalin in the treatment of PDN from the perspective of third-party payers. CHWS Journal Article
Dahal A, McAdam-Marx C, Joy E, Brixner D	A Retrospective Analysis of Follow-up Timing and Blood Pressure Outcomes after Initiation of Antihypertensive Therapy in Patients with Hypertension Treated in a Utah Community Setting	Utah’s Health	01-01-2012		N/A
Nelson R, Hicken B, Cai B, Dahal A, West A, Rupper R	Utilization of Travel Reimbursement in the VA	Journal of Rural Health	04-02-2014	URL	N/A	To improve access to care, the Veterans Health Administration (VHA) increased its patient travel reimbursement rate from 11 to 28.5 cents per mile on February 1, 2008, and again to 41.5 cents per mile on November 17, 2008. We identified characteristics of veterans more likely to receive travel reimbursements and evaluated the impact of these increases on utilization of the benefit. Methods We examined the likelihood of receiving any reimbursement, number of reimbursements, and dollar amount of reimbursements for VHA patients before and after both reimbursement rate increases. Because of our data’s longitudinal nature, we used multivariable generalized estimating equation models for analysis. Rurality and categorical distance from the nearest VHA facility were examined in separate regressions. Findings Our cohort contained 214,376 veterans. During the study period, the average number of reimbursements per veteran was higher for rural patients compared to urban patients, and for those living 50‐75 miles from the nearest VHA facility compared to those living closer. Higher reimbursement rates led to more veterans obtaining reimbursement regardless of urban‐rural residence or distance traveled to the nearest VHA facility. However, after the rate increases, urban veterans and veterans living <50 miles from the nearest VHA facility increased their travel reimbursement utilization slightly more than other patients. Conclusions Our findings suggest an inverted U‐shaped relationship between veterans’ utilization of the VHA travel reimbursement benefit and travel distance. Both urban and rural veterans responded in roughly equal manner to changes to this benefit. CHWS Journal Article
Dahal A, Fertig A	An Econometric Assessment of the Effect of Mental Illness on Household Spending Behavior	Journal of Economic Psychology	08-01-2013	URL	N/A	This paper examines the relationship between individuals’ mental health status and their spending behavior. Compared to individuals without mental health problems, individuals with mental health problems may have higher discount rates and derive greater utility from spending (i.e., retail therapy). If the mentally ill have these characteristics, we would expect them to purchase goods and services that give immediate enjoyment, sacrificing longer-term savings goals. However, mental health disorders may result in a sense of worthlessness and lethargy such that less utility is derived from spending and less energy is available for spending, which would give us the opposite prediction. Using the Panel Study of Income Dynamics, we generally find a negative effect of mental illness on household spending, although the specific effects vary by the measure of mental illness, by the expenditure category, and by gender and couple status. Of particular concern, single and married women with mental illness reduce spending on education, which suggests a long-term financial cost of mental illness. In addition, we find some evidence of retail therapy with respect to a mental health screen for single and married women and with respect to a mental diagnosis for married men. CHWS Journal Article
Dahal A, Bellows BK, Sonpavde G, Tantravahi SK, Choueiri TK, Galsky M, Agarwal N	Incidence of Severe Nephrotoxicity With Cisplatin Based on Renal Function Eligibility Criteria: Indirect Comparison Meta-analysis	Am J Clin Oncol	05-12-2014	URL	N/A	The objective of this meta-analysis was to indirectly compare incidence of nephrotoxicity in trials using cisplatin (CIS) for treatment of solid tumors when renal function was assessed using serum creatinine (SCr) or creatinine clearance (CrCl) for eligibility criteria. CHWS Journal Article
McAdam-Marx C, Dahal A, Jennings B, Singhal M, Gunning K	The effect of a diabetes collaborative care management program on clinical and economic outcomes in patients with type 2 diabetes	J Manag Care Spec Pharm	06-01-2015	URL	N/A	Clinical pharmacy services (CPS) in the primary care setting have been shown to help patients attain treatment goals and improve outcomes. However, the availability of CPS in community-based primary care is not widespread. One reason is that current fee-for-service models offer limited reimbursement opportunities for CPS in the community setting. Furthermore, data demonstrating the value of CPS in this setting are limited, making it difficult for providers to determine the feasibility and sustainability of incorporating CPS into primary care practice. CHWS Journal Article
Dahal A, McAdam-Marx C, Stout B, and McWhorter LS	Improving Diabetes Care in Underserved Patients through a “Learning Your ABCs” Education and Screening Program	Journal of Pharmaceutical Health Care and Sciences	06-01-2015	URL	N/A	Pharmacists are accessible health care professionals and can provide diabetes education and counseling tounderserved patients. Knowledge of hemoglobin A1C, blood pressure and cholesterol (ABC) implications andtreatment targets may improve diabetes self-management. This article describes ABC education in a communitypharmacy with a large uninsured and underinsured patient population. CHWS Journal Article diabetes underserved
Skillman SM, Dahal A, Frogner BK, Andrilla CHA	Medical Assistants in Washington State: Demographic, Education, and Work Characteristics of the State’s Medical Assistant-Certified Workforce	Center for Health Workforce Studies, University of Washington	01-01-2019	Report	Expanding Role of Medical Assistants	Medical assistants (MAs) are a rapidly growing and increasingly important workforce. High MA turnover, however, is common and employers report applicants frequently do not meet their needs. We collected survey responses from a representative sample of Washington’s MAs with certified status (MA-Cs) to understand their demographic, education and employment backgrounds; job satisfaction; and career plans. CHWS CHWS Home News Nursing Reports and Briefs Washington
Skillman SM, Stubbs BA, Aragon, SA	Washington State’s Registered Nurse Workforce: Results of a 2018 Survey	Center for Health Workforce Studies, University of Washington	10-01-2018	Full Report	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 report summarizes the findings from this survey. CHWS Reports and Briefs
Skillman SM, Dahal A, Frogner BK, Andrilla CHA	Frontline workers’ career pathways: A detailed look at Washington State’s medical assistant workforce	Medical Care Research and Review	11-01-2018	URL Policy Brief	Expanding Role of Medical Assistants
Frogner BK, Stubbs BA, Skillman SM	Emerging Roles and Occupations in the Health Workforce	Center for Health Workforce Studies, University of Washington	08-01-2018	Policy Brief Full Report	Emerging Roles in Allied Health Occupations	Systematically quantifying and tracking the evolution of the health workforce is a challenge, yet is important for identifying emerging demands for different skills and competencies. Real Time Labor Market Information (RT-LMI), 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. The purpose of this study is to identify how five domains of emerging roles in healthcare have been incorporated into the job titles and descriptions of healthcare occupations by using RT-LMI data from LinkUp, a job search engine company. The key findings from this study are: “Care coordination” was the most common emerging role appearing in healthcare job ads, either in the job title or job description, in both 2014 and 2015, and “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 (2.0% in 2014 and 3.5% in 2015) 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 may be becoming stand-alone healthcare occupations. 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. Allied Health CHWS CHWS Home News Reports and Briefs care continuum navigator care coordinating care coordination care coordination navigator care coordinator care management care navigation care navigator case manager consumer education coordination of care coordination of patient care disease management disease manager health coach health coaching health educating health education health educator health service navigator health services navigator management of patient care managing disease managing risk navigate care navigate patient care navigation of care nurse navigator patient care coordination patient care management patient navigation patient navigator peer advisor peer advocate peer coach peer counselor peer education peer educator peer liaison peer mentor peer navigator peer partner peer recovery coach peer recovery specialist peer specialist peer support peer support specialist population health risk management
Stubbs BA, Skillman SM	2018 Washington State data snapshot: registered nurses (RNs)	Center for Health Workforce Studies, University of Washington	05-01-2018	Snapshot	2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Stubbs BA, Skillman SM	2018 Washington State data snapshot: registered nurses (RNs)	Center for Health Workforce Studies, University of Washington	05-01-2018	Snapshot	2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Stubbs BA, Skillman SM	2018 Washington State data snapshot: licensed practical nurses (LPNs)	Center for Health Workforce Studies, University of Washington	05-01-2018	Snapshot	2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Stubbs BA, Skillman SM	2018 Washington State data snapshot: advanced registered nurse practitioners (ARNPs)	Center for Health Workforce Studies, University of Washington	05-01-2018	Snapshot	2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Skillman SM, Stubbs BA, Dahal A	Maine’s physician, nurse practitioner, and physician assistant workforce in 2018	Seattle, WA: Center for Health Workforce Studies, University of Washington	07-30-2018	Full Report	N/A	Compared with 2014, Maine had slightly fewer licensed physicians, and more NPs and PAs in Maine for every 100,000 state residents in 2018. Mean ages of physicians were the same, but NPs’ and PAs’ mean ages each decreased by one year from 2014 to 2018. Maine’s practicing physician supply, on a per capita basis, was somewhat larger than national averages, both overall and for primary care. The number of primary care physicians per capita varied greatly by county, with more than twice as many in counties with the highest physician density compared with counties having the lowest density. Half or more of the physicians in many of Maine’s most rural counties were age 55 or older. Nearly a quarter of Maine’s total 2018 practicing physician supply graduated from medical school at one of the three colleges affiliated with Maine Medical Center. About 27% of all of Maine’s physicians in 2018 – 42% of primary care physicians, and more than half in family medicine specialties – completed a residency in Maine, which is an overall increase from 2014. Comparisons of county-level physician, NP and PA workforce supply with indicators of population health show some areas of the state where the availability of providers may be affecting access to healthcare, suggesting areas for further examination. CHWS CHWS Home News Physicians Reports and Briefs AMA demographics Maine NP Nurse Practitioner PA Physician physician assistant residency supply
Frogner BK, Harwood K, Andrilla CHA, Schwartz MR, Pines JM	Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs	Health Services Research	05-23-2018	URL	Direct Access to Physical Therapists	health care costs imaging insurance claims opioid Physical therapy
Frogner, BK	Update on the Stock and Supply of Health Services Researchers in the United States	Health Services Research	06-04-2018	URL	N/A	diversity education health care Health services research workforce
Snyder CR, Dahal A, Frogner BK	Occupational Mobility among Individuals in Entry‐level Healthcare Jobs in the United States	Journal of Advanced Nursing	03-31-2018	URL Policy Brief	Career Paths of Allied Health Professionals	To explore career transitions among individuals in select entry-level healthcare occupations. Journal Article News allied health career pathways health workforce job mobility nursing panel data
Snyder CR, Frogner BK, Skillman SM	Facilitating Racial and Ethnic Diversity in the Health Workforce	Journal of Allied Health	03-01-2018	URL	Facilitating Racial and Ethnic Diversity in the Health Workforce	Racial and ethnic diversity in the health workforce can facilitate access to healthcare for underserved populations and meet the health needs of an increasingly diverse population. In this study, we explored 1) changes in the racial and ethnic diversity of the health workforce in the United States over the last decade, and 2) evidence on the effectiveness of programs designed to promote racial and ethnic diversity in the U. S. health workforce. Findings suggest that although the health workforce overall is becoming more diverse, people of color are most often represented among the entry-level, lower-skilled health occupations. Promising practices to help facilitate diversity in the health professions were identified in the literature, namely comprehensive programs that integrated multiple interventions and strategies. While some efforts have been found to be promising in increasing the interest, application, and enrollment of racial and ethnic minorities into health profession schools, there is still a missing link in understanding persistence, graduation, and careers. Journal Article News
Gattman NE, McCarty RL, Balassa A, Skillman SM	Washington State Behavioral Health Workforce Assessment	Washington Workforce Training and Education Coordinating Board	12-01-2017	Full Report	Washington State Behavioral Health Workforce Assessment
McCarty RL, Skillman SM	Washington State's Behavioral Health Workforce (profiles)	Center for Health Workforce Studies, University of Washington	12-01-2017	Chemical Dependency Counselors Community Health Workers ... View more	Washington State Behavioral Health Workforce Assessment
Patterson DG, Andrilla CHA, Schwartz MR, Hager LJ, Skillman SM	Assessing the Impact of Washington State’s Oral Health Workforce on Patient Access to Care	Seattle, WA: Center for Health Workforce Studies, University of Washington	11-09-2017	Final Report Policy Brief	The Status of the Oral Health Workforce in Washington State	dentist licensure
Skillman SM, Dahal A	Alaska's physician workforce in 2016	Center for Health Workforce Studies, University of Washington	07-28-2017	Full Report	Alaska’s Physician Workforce
Skillman SM, Dahal A	Wyoming’s physician workforce in 2016	Center for Health Workforce Studies, University of Washington	04-01-2017	Full Report	Wyoming’s Physician Workforce
Stubbs BA, Frogner BK, Skillman SM	The value of real time labor market information for monitoring health workforce demand: a case study examining employer demand for health information technology skills	Center for Health Workforce Studies, University of Washington	03-01-2017	Full Report Policy Brief	Emerging Health IT Roles and Skillsets
Skillman SM, Dahal A	Montana’s physician workforce in 2016	Center for Health Workforce Studies, University of Washington	03-01-2017	Full Report	Montana Physician Workforce
Skillman SM, Dahal A	Idaho’s physician workforce in 2016	Center for Health Workforce Studies, University of Washington	02-01-2017	Full Report	Idaho’s Physician Workforce
Boat TF, Land ML, Leslie LK, Haogwood KE, Hawkins-Walsh E, McCabe MA, Fraser MW, deSaxe Zerden L, Lombardi BM, Fritz GK, Frogner BK, Hawkins JD, Sweeney M	Workforce development to enhance the cognitive, affective, and behavioral health of children and youth: opportunities and barriers in child health care training	Perspectives: Expert Voices in Heath & Health Care, National Academy of Medicine. 29p	11-29-2016	URL	N/A
Frogner BK, Wu X, Ku L, Pittman P, Masselink LE	Do years of experience with electronic health records matter for productivity in community health centers?	Journal of Ambulatory Care Management	01-01-2017	URL	N/A	This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience. CHWS Journal Article community health center electronic health records health IT productivity safety net providers workforce
Frogner BK, Wu X, Park J, Pittman P	The association of electronic health record adoption with staffing mix in community health centers	Health Services Research	01-27-2017	URL	N/A	Objective To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs). Study Setting Community health centers within the 50 states and Washington, DC. Study Design Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit. Data Collection 2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011. Principal Findings Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians. Conclusions Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider. CHWS Journal Article News administrative data uses Econometrics health workforce: distribution/incomes/training information technology in health uninsured/safety net providers
Frogner BK	The health care job engine: where do they come from and what do they say about our future?	Medical Care Research and Review	01-19-2017	URL	N/A	Health care has been cited as a job engine for the U.S. economy. This study used the Current Population Survey to examine the sector and occupation shifts that underlie this growth trend. Health care has had a cyclical relationship with retail trade, leisure and hospitality, education, and professional services. The entering workforce has been increasingly taking on low-skilled occupations. The exiting workforce has not been necessarily retiring or going back to school, but appeared to be leaving without a job, with potentially more child care duties, and with high rates of disability and poverty levels. This study also found that the number of workers staying in health care has been slowly declining over time. As the United States moves toward team-based care, more attention should be paid to the needs of the lower skilled workers to reduce turnover and ensure delivery of quality care. Allied Health CHWS Hospitals Journal Article National News Nursing Other Work Settings Physicians health care industry health care workforce job growth job mobility turnover
Skillman SM, Dahal A	Washington State’s physician workforce in 2016	Center for Health Workforce Studies, University of Washington	02-01-2017	Full Report	Washington State’s Physician Workforce
Patterson DG, Snyder CR, Frogner BK	Immigrants in healthcare occupations	Center for Health Workforce Studies, University of Washington	01-01-2017	Full Report Policy Brief	Immigrants in Allied Health Professions
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - diagnostic related technologists and technicians	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - medical assistants	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - occupational therapists	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - physical therapists	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - social workers	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - speech-language pathologists	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - clinical laboratory technologists and technicians	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - dental hygienists	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - respiratory therapists	Center for Health Workforce Studies, University of Washington	01-05-2017	Data Snapshot	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA	Leveraging data to monitor the allied health workforce: national supply estimates using different data sources	Center for Health Workforce Studies, University of Washington	12-01-2016	Policy Brief Full Report	Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Frogner BK, Skillman SM, Patterson DG, Snyder CR	Comparing the socioeconomic well-being of workers across healthcare occupations	Center for Health Workforce Studies, University of Washington	12-01-2016	Full Report Policy Brief	Impacts of Greater Use of Low Skilled, Low-wage Workers in Health Care Delivery
Frogner BK, Skillman SM	Pathways to middle-skill allied health care occupations	Issues in Science & Technology	11-30-2016	URL	N/A	Better information about the skills required in health occupations and the paths to career advancement could provide opportunities for workers as well as improved health care. Health care has been a “job engine” for the US economy, given the sector’s historically strong job growth, an aging population, and increasing demand for health care due to the Patient Protection and Affordable Care Act of 2010 (ACA). Health care professions dominate the list of the 20 fastest growing occupations, with growth rates between 25% and 50%, according to data compiled by the federal Bureau of Labor Statistics. With a good demand outlook and the relatively low entry requirements for several of these jobs, health care occupations appear to be a good career path. Many of the growing health care professions are “middle-skill,” a term with considerable overlap with the term “allied health,” a category that encompasses a diverse and not precisely defined set of careers. The Association of Schools of Allied Health Professions has identified 66 such occupations; the Health Professions Network, a collaborative group representing the leading allied health professions, has identified over 45; and the Commission on Accreditation of Allied Health Education Programs provided accreditation in 2010 to 28 occupations. These jobs may or may not involve direct patient care, and some do not require specialized skill at entry. Many require less than a baccalaureate degree for entry. The pathway to an allied health career can be unclear, especially in relatively new and emerging positions. Clear career pathways and ladders that lead to socioeconomic success need to be clarified in order to direct investments for attracting and retaining a competent workforce. Our task here, then, is to describe what is known about the career pathways into middle-skill allied health careers and the challenges that exist for individuals seeking such careers. Allied Health CHWS Journal Article allied healthcare apprenticeship career pathways education health occupations training workforce
Gattman N, Reule R, Balassa A, Skillman SM, McCarty RL, Schwartz MR	Washington's behavioral health workforce assessment: project phase I	Washington State Workforce Training and Education Coordinating Board	11-01-2016	Final Report	Washington State Behavioral Health Workforce Assessment
McCarty RL, Schwartz MR, Skillman SM	Washington’s behavioral health workforce assessment: input from key informants	Center for Health Workforce Studies, University of Washington	11-18-2016	Full Report Policy Brief	Washington State Behavioral Health Workforce Assessment
Roberts FA, DiMarco AC, Skillman SM, Mouradian WE	Growing the dental workforce for rural communities: University of Washington’s RIDE program	Generations: Journal of the American Society on Aging	11-17-2016	URL	N/A	Older adults constitute a growing percentage of the rural population in the United States. This cohort is at special risk for oral health problems because access to dental care is an ongoing challenge in rural America. The University of Washington School of Dentistry’s Regional Initiatives in Dental Education (RIDE) program delivers intensive, community-based education that prepares dentists to meet the needs of rural and underserved populations, including the growing number of rural elders. Of those graduates who have completed their training, 70 percent are practicing in rural or underserved areas. CHWS Journal Article News Washington aging in community dental education Generations health and wellness healthcare and aging oral health rural workforce
Frogner BK, Skillman SM, Snyder CR	Characteristics of veterans in allied healthcare occupations	Center for Health Workforce Studies, University of Washington	11-11-2016	Full Report Policy Brief	Characteristics of Veterans in Allied Health Care Jobs
Miller SC, Frogner BK, Saganic LM, Cole AM, Rosenblatt RA	Affordable Care Act impact on community health center staffing and enrollment: a cross-sectional study	Journal of Ambulatory Care Management	10-01-2016	URL	N/A	Over 500 000 Washingtonians gained health insurance under the Affordable Care Act (ACA). As more patients gain insurance, community health centers (CHCs) expect to see an increase in demand for their services. This article studies the CHCs in Washington State to examine how the increase in patients has been impacting their workload and staffing. We found a reported mean increase of 11.7% and 5.4% in new Medicaid and Exchange patients, respectively. Half of the CHCs experienced large or dramatic workload impact from the ACA. Our findings suggest that CHCs need further workforce support to meet the expanding patient demand. CHWS Journal Article News Affordable Care Act community health centers
Pittman P, Masselink L, Bade L, Frogner BK, Ku L	Factors determining medical staff configurations in community health centers: CEO perspectives	Journal of Healthcare Management	09-01-2016	URL	N/A	While financial incentives to adopt team-based care are mounting, little is known about how leaders of primary care organizations make decisions regarding medical staff configurations. This study explores perceptions of CEOs of community health centers (CHCs) that have a variety of staff configurations. We used the 2012 Uniform Data System to identify a maximum variety sample of CHCs with unusually high proportions of advanced practice providers, nurses, medical assistants, case managers, or community health workers. We conducted semistructured interviews with CEOs at 19 selected CHCs about factors that influenced their medical staff configuration decisions. We found that CEOs considered two major dimensions in their decisions: choice and balance of providers (physicians versus nurse practitioners [NPs] and physician assistants [PAs]) and configuration of clinical support staff. Across these decision domains, CEOs consider contextual issues (e.g., local labor supply, wage gaps between professions, scope of practice regulations, local payment policies, and institutional history), as well as their own perceptions of individual attributes, the quality of specific professions, and the likelihood of retention. Strong preferences emerged for a balance among physicians and NPs/PAs and the inclusion of nurses with “stackable” degrees. This study provides a preliminary framework for understanding how CEOs at CHCs weigh staffing options in a variety of contexts. This framework can serve to inform research on the comparative effectiveness of different staffing configurations and improve national and state workforce projection models. CHWS Journal Article advanced practice providers case managers CEOs CHCs community health workers medical assistants NP nurse practitioners nurses PA primary care staff configuration
Lutfiyya MN, Tomai L, Frogner BK, Cerra F, Zismer D, Parente S	Does primary care diabetes management provided to Medicare patients differ between primary care physicians and nurse practitioners?	Journal of Advanced Nursing	01-01-2017	URL	N/A
Skillman SM, Andrilla CHA, Patterson DG, Fenton SH, Ostergard SJ	Health information technology workforce needs of rural primary care practices	J Rural Health. Winter 2015, 31(1):58-66	12-01-2015		N/A
Kaplan L, Klein TA, Skillman SM, Andrilla CHA	Faculty supervision of NP program practicums: a comparison of rural and urban site differences	The Nurse Practitioner	07-01-2016		N/A
Andrilla CHA, Skillman SM	Washington State data snapshot: licensed practical nurses (LPNs)	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2016	Snapshot	2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Andrilla CHA, Skillman SM	Washington State data snapshot: advanced registered nurse practitioners (ARNPs)	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2016	Snapshot	2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Andrilla CHA, Skillman SM	Washington State data snapshot: registered nurses (RNs)	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2016	Snapshot	2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Snyder CR, Wick KH, Skillman SM, Frogner BK	Pathways for military veterans to enter healthcare careers	Center for Health Workforce Studies, University of Washington	05-01-2016	Full Report Policy Brief	Pathways for Military Veterans to Enter Allied Health Careers
Skillman SM, Snyder CR, Frogner BK, Patterson DG	The behavioral health workforce needed for integration with primary care: information for health workforce planning	Center for Health Workforce Studies, University of Washington	04-20-2016	Full Report Policy Brief	The Workforce Needed to Integrate Behavioral/Mental Health Workforce with Primary Care
Frogner BK, Harwood K, Pines J, Andrilla CHA, Schwartz MR	Does unrestricted direct access to physical therapy reduce utilization and health spending?	Health Care Cost Institute and National Academy for State Health Policy State Health Policy Grant Program. Washington, DC: Health Care Cost Institute.	01-01-2016	URL	Direct Access to Physical Therapists
National Academies of Sciences Engineering and Medicine	A framework for educating health professionals to address the social determinants of health	Washington, DC: The National Academies Press	01-01-2016	URL	Educating Health Professionals to Address the Social Determinants of Health
Forte G, Graham K, Frogner BK	Commentaries on health services research	Journal of the American Academy of Physician Assistants	01-01-2016	URL	N/A	A cornerstone of patient-centered medical homes (PCMHs) is team-based care; however, little information exists on the composition of providers delivering direct primary care in PCMHs. This study examined the number and distribution of primary care physicians, NPs, and PAs in New York state practices (n=7,431). Designated PCMHs had more NPs and PAs per primary care physician relative to non-PCMHs. The ratios of NPs to primary care physicians were almost twice as high in PCMHs compared with non-PCMHs (0.20 and 0.11), and ratios were similarly different for PAs to primary care physicians (0.16 and 0.09, respectively). The multivariate analyses also support that higher NP and PA staffing was associated with PCMH designation—that is, for every 25 primary care physicians, PCMHs had one additional NP and/or PA. The growth of PCMHs may require more NPs and PAs to meet the anticipated growth in demand for healthcare. Policy- and practice-level changes are necessary to use them in the most effective ways. CHWS Journal Article NP PA patient-centered medical homes PCHM PCP primary care physicians primary care provider team-based care
Frogner BK, Pauley GC	Do skill mix and high tech matter for hospitals’ competency in adopting electronic health records?	Health Economics Outcomes Research (Open Access)	01-01-2015	URL	N/A	Health workforce plays an important role in the adoption of electronic health records (EHRs). Hospitals have cited barriers around hiring a competent workforce to adopt EHRs. The literature does not adequately relate organizational and health workforce competency with EHR adoption, which makes it difficult to monitor and evaluate any programs targeting trying to improve this problem. In this study, we develop an index measuring hospitals’ competency in adopting electronic health records (EHRs) using Item Response Theory. We test to what extent hospitals’ skill mix and high tech capacity influence their competency. We use health IT data from Health Information and Management Systems Society (HIMSS) Analytics Database and workforce and high tech data from the Centers of Medicare and Medicaid Services (CMS) Provider of Services file. We found that hospitals with a larger share of registered nurses (RNs) had higher EHR competency, but environments with more high tech potentially compete for their attention and results in lower EHR competency. Technicians, therapists, and lower skilled nurses that interact with high tech apparently transfer their knowledge and skills into higher EHR competency. Future EHR adoption incentives should target lower competency hospitals with insufficient workforce and less technological capacity CHWS Journal Article Capital-skill complementarity EHR health IT health workforce Item response theory Organizational competency
Frogner BK, Parente ST, Frech HE	Comparing efficiency of health systems across industrialized countries: a panel analysis	BMC Health Services Research	01-01-2015	URL	N/A	BACKGROUND: Rankings from the World Health Organization (WHO) place the US health care system as one of the least efficient among Organization for Economic Cooperation and Development (OECD) countries. Researchers have questioned this, noting simplistic or inappropriate methodologies, poor measurement choice, and poor control variables. Our objective is to re-visit this question by using newer modeling techniques and a large panel of OECD data. METHODS: We primarily use the OECD Health Data for 25 OECD countries. We compare results from stochastic frontier analysis (SFA) and fixed effects models. We estimate total life expectancy as well as life expectancy at age 60. We explore a combination of control variables reflecting health care resources, health behaviors, and economic and environmental factors. RESULTS: The US never ranks higher than fifth out of all 36 models, but is also never the very last ranked country though it was close in several models. The SFA estimation approach produces the most consistent lead country, but the remaining countries did not maintain a steady rank. DISCUSSION: Our study sheds light on the fragility of health system rankings by using a large panel and applying the latest efficiencymodeling techniques. The rankings are not robust to different statistical approaches, nor to variable inclusion decisions. CONCLUSIONS: Future international comparisons should employ a range of methodologies to generate a more nuanced portrait of healthcare system efficiency. CHWS Journal Article Efficiency Health systems International comparison Life expectancy Stochastic frontier analysis
Frogner BK, Spetz J, Oberlin S, Parente ST	The Demand for Healthcare Workers Post-ACA	International Journal of Health Economics and Management	01-01-2015	URL	N/A	Concern abounds about whether the health care workforce is sufficient to meet changing demands spurred by the Affordable Care Act (ACA). We project that by 2022 the health care industry needs three to four million additional workers, forty percent of which is related to demand growth under the ACA. We project faster job growth in the ambulatory care sector, especially in home health care. Given the current profile, we expect that the future health care workforce will be increasingly female, young, racially/ethnically diverse, not US-born, at or below the poverty level and at a low level of educational attainment. CHWS Journal Article health reform health workforce microsimulation projections
Ku L, Frogner BK, Steinmetz E, Pittman P	Many paths to primary care: flexible staffing and productivity in community health centers	Health Affairs	01-01-2015	URL	Impact of Electronic Health Records on Community Health Center Staffing	Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served. CHWS Journal Article community health centers confidence intervals medicaid patients medical practice nurses nursing patient care physicians primary care uninsured
Skillman SM, Hager LJ, Frogner BK	Incentives for Nurse Practitioners and Registered Nurses to Work in Rural and Safety Net Settings	Seattle, WA: UW Center for Health Workforce Research Studies	01-01-2015	Rapid Turnaround Brief	N/A
Skillman SM, Palazzo L, Hart LG, Keepnews D	The characteristics of registered nurses whose licenses expire: why they leave nursing and implications for retention and re-entry	Nurs Econ	05-01-2010	URL	RNs with Expired Licenses in Washington	Little is known about RNs who drop their licenses and their potential re-entry into the nursing workforce. The results of this study provide insight into reasons nurses leave their careers and the barriers to re-entry, all important indicators of the current professional climate for nursing. While representing only one state, these findings suggest that RNs who allow their licenses to expire do so because they have reached retirement age or, among those who do not cite age as a factor, because many are unable or unwilling to work in the field. Inactive nurses who might otherwise appear to be likely candidates for re-entry into the profession may not be easily encouraged to practice nursing again without significant changes in their personal circumstances or the health care work environment. Effective ways to address current and pending RN workforce shortages include expanding RN education capacity to produce more RNs who can contribute to the workforce across the coming decades, and promote work environments in which RNs want to, and are able to, practice across a long nursing career. CHWS Journal Article Washington education license RN workforce
Skillman SM, Stover B	Idaho's physician workforce in 2014	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	09-01-2014	Full Report	Idaho’s Physician Workforce
Skillman SM, Stover B	Alaska’s physician workforce in 2014	Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington	12-29-2015	Full Report	Alaska’s Physician Workforce
Frogner BK, Westerman B, DiPietro L	The value of athletic trainers in ambulatory settings	Journal of Allied Health	01-01-2015		Value of Athletic Trainers in Ambulatory Care Settings
Westerman B, Frogner BK, DiPietro L	Hiring patterns of athletic trainers in ambulatory settings	International Journal of Athletic Therapy and Training	01-01-2015		Value of Athletic Trainers in Ambulatory Care Settings
Frogner BK, Spetz J	Exit and entry of workers in long-term care	San Francisco, CA: UCSF Health Workforce Research Center on Long-Term Care	01-01-2015	URL	Entry and Exit of Workers in Long-Term Care
Skillman SM, Stover B	Wyoming's physician workforce in 2014	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-11-2014	Full report	Wyoming’s Physician Workforce
Patterson DG, Skillman SM, Andrilla CHA	Data snapshots: Wyoming health care providers, 2009	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-31-2009	Physicians Physician Assistants Advanced Practice Nurses Pharmacists Dentists Psychologists Licensed Professional Counselors Licensed Clinical Social Workers Licensed Marriage & Family Therapists Licensed Addiction Therapists	Wyoming Health Care Workforce Distribution and Policy Analyses
Patterson DG, Skillman SM, Doescher MP, Andrilla CHA	Obstacles to providing high-quality patient care: findings from a survey of Wyoming's medical care providers	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-31-2009	Full report Policy brief	Wyoming Health Care Workforce Distribution and Policy Analyses
Patterson DG, Skillman SM, Andrilla CHA, Doescher MP	Workforce challenges in delivering health care to elderly and low-income populations in Wyoming: medical providers' acceptance of Medicaid and Medicare patients	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	09-30-2009	Full report Policy brief	Wyoming Health Care Workforce Distribution and Policy Analyses
Skillman SM, Andrilla CHA, Doescher MP, Robinson BJ	Wyoming primary care gaps and policy options	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	12-01-2008	Full report	Wyoming Health Care Workforce Distribution and Policy Analyses
WWAMI Center for Health Workforce Studies, University of Washington	Data snapshot: current osteopathic physician workforce in the WWAMI states	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-01-2007	Snapshot	Physician Workforce in WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho): 2005
Chen FM, Fordyce MA, Hart LG	WWAMI Physician Workforce 2005	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	01-01-2005	Full report	Physician Workforce in WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho): 2005
Patterson DG, Skillman SM, Hart LG	Washington State's radiographer workforce through 2020: influential factors and available data	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	01-01-2004	Full report Policy brief	Washington State's Radiographer Workforce Through 2020: Influential Factors and Available Data
Patterson DG, Skillman SM, Hart LG	Washington State's pharmacist workforce through 2020: influential factors and available data	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	01-01-2004	Full report Policy brief	Washington State's Pharmacist Workforce through 2020: Influential Factors and Available Data
Skillman SM, Andrilla CHA, Alves-Dunkerson JA, Mouradian WE, Comenduley M, Yi J, Doescher MP	Washington State's oral health workforce	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-31-2009	Full report	Assessment of the Oral Health Workforce in Washington State
Andrilla CHA, Hart LG	Practice patterns and characteristics of dental hygienists in Washington State	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-01-2007	Full report	Washington's Dental Hygienists: 2004 Survey Findings
Patterson DG, Skillman SM, Hart LG	Washington State's dental hygienist workforce through 2020: influential factors and available data	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	01-01-2004	Full report Policy brief	Washington State's Dental Hygienist Workforce through 2020: Influential Factors and Available Data
Skillman SM, Andrilla CHA, Tieman L, Doescher MP	Demographic, education, and practice characteristics of registered nurses in Washington State: results of a 2007 survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2008	Full report Policy brief	Demographic, Education, and Practice Characteristics of Registered Nurses in Washington State: Results of a 2007 Survey
Skillman SM, Andrilla CHA, Tieman L, McCook AU	Washington State registered nurse supply and demand projections: 2011-2031	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	12-31-2011	Full report Policy brief	Projections of Washington State RN Supply and Demand through 2031
Skillman SM, Andrilla CHA, Hart LG	Washington State registered nurse supply and demand projections: 2006-2025	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2007	Full report Policy brief	Projections of Washington State RN Supply and Demand through 2025
Skillman SM, Andrilla CHA, Ostergard SJ	Washington State registered nurses - analysis of RNs who did not renew their licenses: 2008-2014	Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington	09-30-2014	Full report	Washington State Registered Nurses – Analysis of RNs who did not renew their licenses: 2008-2014
Skillman SM, Stover B	Washington State's physician workforce in 2014	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-14-2014	Full report	Washington State’s Physician Workforce
Dresden GM, Baldwin LM, Andrilla CHA, Skillman SM, Benedetti TJ	Influence of obstetric practice on workload and practice patterns of family physicians and obstetrician-gynecologists	Ann Fam Med	01-01-2008	URL	Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State	PURPOSE: Obstetric practice among family physicians has declined in recent years. This study compared the practice patterns of familyphysicians and obstetrician-gynecologists with and without obstetric practices to provide objective information on one potential reason for this decline–the impact of obstetrics on physician lifestyle. METHODS: In 2004, we surveyed all obstetrician-gynecologists, all rural family physicians, and a random sample of urban family physiciansidentified from professional association lists (N =2,564) about demographics, practice characteristics, and obstetric practices. RESULTS: A total of 1,197 physicians (46.7%) overall responded to the survey (41.5% of urban family physicians, 54.7% of rural familyphysicians, and 55.0% of obstetrician-gynecologists). After exclusions, 991 were included in the final data set. Twenty-seven percent of urban family physicians, 46% of rural family physicians, and 79% of obstetrician-gynecologists practiced obstetrics. The mean number of total professional hours worked per week was greater with obstetric practice than without for rural family physicians (55.4 vs 50.2, P=.005) and for obstetrician-gynecologists (58.3 vs 43.5, P = .000), but not for urban family physicians (47.8 vs 49.5, P = .27). For all 3 groups, physicianspracticing obstetrics were more likely to provide inpatient care and take call than physicians not practicing obstetrics. Large proportions of family physicians, but not obstetrician-gynecologists, took their own call for obstetrics. Concerns about the litigation environment and personal issues were the most frequent reasons for stopping obstetric practice. CONCLUSIONS: Practicing obstetrics is associated with an increased workload for family physicians. Organizing practices to decrease the impact on lifestyle may support family physicians in practicing obstetrics. CHWS Complete Journal Article Nursing Physicians Washington Family medicine lifestyle obstetrics practice patterns rural health care workload
Benedetti TJ, Baldwin LM, Skillman SM, Andrilla CHA, Bowditch E, Carr KC, Myers SJ	Professional liability issues and practice patterns of obstetrical providers in Washington State	Obstet Gynecol	06-01-2006	URL	Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State	OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers‘ most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington‘s obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study’s results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III. Comment in Medical professional liability revisited. [Obstet Gynecol. 2006] CHWS Complete Journal Article Nursing Physicians Washington certified nurse midwives family physicians gynecologists liability premiums licensed midwives maternity care midwifery obstetrician–gynecologists obstetricians practice patterns Professional liability registered nurses
Benedetti TJ, Baldwin LM, Andrilla CHA, Hart LG	The productivity of Washington State's obstetrician-gynecologist workforce: does gender make a difference?	Obstet Gynecol	01-01-2004	URL	Obstetrics and Gynecology Specialty Services: Supply, Distribution, and the Effect of Changing Demography in Washington State	OBJECTIVE: To compare the practice productivity of female and male obstetrician-gynecologists in Washington State. METHODS: The primary data collection tool was a practice survey that accompanied each licensed practitioner’s license renewal in 1998-1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births. RESULTS: Of the 541 obstetrician-gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P < or =.01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P < or =.05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P <.01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30-39 through the 50-59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40-49 age group. CONCLUSION: Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician-gynecologists in Washington State. Changing demographics and behaviors of the obstetrician-gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States. LEVEL OF EVIDENCE: II-3 CHWS Complete Journal Article Physicians Washington obstetrician–gynecologists practice productivity
Benedetti TJ, Baldwin LM, Andrilla CHA, Hart LG	The productivity of Washington State's obstetrician-gynecologist workforce: does gender make a difference?	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-01-2003	Full report	Obstetrics and Gynecology Specialty Services: Supply, Distribution, and the Effect of Changing Demography in Washington State
Andrilla CHA, Skillman SM, Tieman L	Demographic, education, and practice characteristics of licensed practical nurses in Washington State: results of a 2007 survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	01-01-2009	Full report Policy brief	Demographic, Education, and Practice Characteristics of Licensed Practical Nurses in Washington State: Results of a 2007 Survey
Skillman SM, Andrilla CHA, Patterson DG, Tieman L, Doescher MP	The licensed practical nurse workforce in the United States: one state's experience	Cah Sociol Demogr Med	06-01-2010	URL	Projections of Washington State LPN Supply and Demand through 2025	BACKGROUND: Licensed practical nurses (LPNs) are employed in multiple health care settings in the United States, with the largest portion providing nursing care in long-term care, skilled nursing, and nursing home facilities, which largely provide custodial care and rehabilitative services to elderly residents. Rapid growth in the size of the elderly population in the U.S., combined with retirements from an aging LPN workforce, are expected to increase the demand for LPNs in the coming decades. This paper describes the characteristics of LPNs in one state, Washington, and makes projections of LPN supply and demand in the state through 2026. METHODS: The study uses data from a 2007 survey of LPNs with Washington State licenses to describe the demographic, education, and practice characteristics of the workforce. The projections of LPN supply and demand were built from the baseline survey data and changes over time were estimated using available data and literature from a variety of sources. RESULTS: Of the 14,446 LPNs with Washington licenses in 2007, 72% practiced in the state. The work setting in which the largest percentage worked was long-term care (37%). Of the average 37 hours worked per week by LPNs, 25 hours were spent in direct patient care. The average age of practicing LPNs was 46 and 12% of LPNs were male. The racial/ethnic distribution of Washington’s LPNs resembled that of the overall state population, with 17% non-White and 4% Hispanic. Nearly three quarters obtained their LPN education within Washington. If the 2007 number of completions from LPN schools in Washington is sustained, the projected supply of practicing LPNs in 2026 will be more than 3,500 (24%) below estimated demand. If the current education completion number increased by 200 LPNs (nearly 20%) in 2011, and this number was maintained through 2026, the projected supply of practicing LPNs would increase but would still be 2,052 LPNs below estimated demand in 2026. Neither projection scenario produces enough LPNs to maintain the 2007 LPN-to-population ratio through 2026. CONCLUSIONS/POLICY IMPLICATIONS: It is not known precisely whether or how LPN workforce roles will change in the future, but the projected LPN shortages in Washington State mirror similar findings from other parts of the U.S., with major growth in projected LPN demand due to increases in, and aging of the state’s population. The number of LPNs completing education programs in the state is unlikely to keep pace with the decline in supply from retirements unless a significant expansion of education programs takes place. The LPN profession is an important entry point into the nursing profession, and increasing the number of LPNs educated in-state could expand the pipeline leading to registered nurse (RN) careers, another nursing profession for which major shortages are predicted. Carefully articulated LPN-to-RN education programs could improve the attractiveness of the profession and increase the supply of LPNs. CHWS Complete Journal Article Nursing Washington licensed practical nurses LPN workforce
Skillman SM, Andrilla CHA, Patterson DG, Thomas A, Tieman L	Washington State licensed practical nurse supply and demand projections: 2007-2026	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-27-2009	Full report Policy brief.	Projections of Washington State LPN Supply and Demand through 2025
Skillman SM, Hutson T, Andrilla CHA, Berkowitz B, Hart LG	How are Washington's hospitals affected by the nursing shortage? Results of a 2001 survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	05-01-2002	Washington's Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Phippen E, Hutson T, Bowditch E, Praseuth T	Washington State hospitals: results of 2005 workforce survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-01-2005	Full report Policy brief	Washington's Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Hutson T, Deacon H, Praseuth T	Washington State hospitals: results of 2003/04 workforce survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	10-01-2004	Full report Policy brief	Washington's Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Hutson T, Andrilla CHA	Washington State hospitals: results of 2002 workforce survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	08-01-2003	Full report Policy brief	Washington's Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Kaplan L, Brown MA	Demographic, education, and practice characteristics of advanced registered nurse practitioners in Washington State: results of a 2008 survey	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	04-01-2009	Full report Policy brief	Demographic, Education, and Practice Characteristics of Advanced Registered Nurse Practitioners in Washington State: Results of a 2008 Survey
Skillman SM, Sadow-Hasenberg J, Hart LG, Henderson T	The effects of the Workforce Investment Act of 1998 on health workforce development in the states	Washington, DC: Bureau of Health Professions, Health Resources and Services Administration, National Center for Health Workforce Analysis	11-01-2004	Full report	The Workforce Investment Act of 1998: Are States Targeting the Health Workforce?
Rosenblatt RA, Rosenblatt FS	The role and function of small isolated public health departments: a case study in three western states	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2001	Policy brief	Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)
Rosenblatt RA, Rosenblatt FS	The role and function of small isolated public health departments: a case study in three western states	Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington	06-01-2001	Policy brief	Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)
Richardson M, Casey S, Rosenblatt RA	Local health districts and the public health workforce: a case study of Wyoming and Idaho	J Public Health Manag Pract	01-01-2001	URL Policy brief	Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)	This study of personnel in local health departments (LHDs) focused on two predominantly rural states: Idaho and Wyoming. Although in the same region of the country, the structure of local public health is different in each state. Idaho’s regionalized LHDs are relatively autonomous, whereas Wyoming’s are county based, with many public health functions retained at the state level. The majority of professionals are nurses followed by environmental health workers and sanitarians, similar to data reported nationally. With increased emphasis on core public health functions of policy, assurance, and assessment, rural LHDs will be challenged to redirect the functions of their workforce. CHWS Complete Idaho Journal Article Nursing Other/Multiple Wyoming health workers local health districts (LHD) nurses sanitarians workforce
Rosenblatt RA, Casey S, Richardson M	Rural-urban differences in the public health workforce: findings from local health departments in three rural western states	Am J Public Health	01-01-2002	URL Policy brief	Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)	Most local health departments or districts are small and rural; two thirds of the nation’s 2832 local health departments serve populations smaller than 50000 people.1 Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services2 during a period when the health care system of which they are a part is undergoing change.3 This study provided quantitative, population based data on the supply and composition of the rural public health workforce in 3 extremely rural states: Alaska, Montana, and Wyoming. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across states in staffing levels, and difficulties experienced in recruiting and retaining personnel. Alaska CHWS Complete Journal Article Montana Nursing Other/Multiple Wyoming local health departments public health professionals rural vs urban workforce
Skillman SM, Fordyce MA, Yen W, Mounts T

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