An aging population and growing disease burden will require a large and specialized health care workforce by 2025

Patient-centered Medical Homes and Access to Services for New Primary Care Patients

BACKGROUND

Recent efforts to revitalize primary care have centered on the patient-centered medical home (PCMH). Although enhanced access is an integral component of the PCMH model, the effect of PCMHs on access to primary care services is understudied.

OBJECTIVE

To determine whether PCMH practices are associated with better access to new appointments for nonelderly adults by direct measurement.

RESEARCH DESIGN

We estimated the relationship between practice PCMH status and access to care in multivariate regression models, adjusting for a robust set of patient, practice, and geographic characteristics; using data on 11,347 simulated patient calls to 7266 primary care practices across 10 US states merged with data on PCMH practices.

PARTICIPANTS

Trained field staff posing as patients (age younger than 65 y) seeking a new primary care appointment with varying insurance status (private, Medicaid, or self-pay).

MEASURES

Our primary predictor was practice PCMH status and our primary outcome was the ability of simulated patients to schedule a new appointment. Secondary outcomes included the number of days to that appointment; availability of after-hour appointments; and an appointment with an ongoing primary care provider.

RESULTS

Of the 7266 practices contacted for an appointment, 397 (5.5%) were National Committee for Quality Assurance-recognized PCMHs. In adjusted analyses, callers to PCMH practices compared with non-PCMH practices were more likely to schedule a new appointment (adjusted odds ratio=1.26 (95% CI, 1.01-1.58); P=0.04] and be offered after-hour appointments [adjusted odds ratio=1.36 (95% CI, 1.04-1.75); P=0.02].

DISCUSSION

PCMH practices maybe associated with better access to new primary care appointments for nonelderly adults, those most likely to gain insurance under the Affordable Care Act.

The Patient-Centered Medicine as the Theoretical Framework for Patient Engagement

The present contribution will describe the origin, development and main characteristics of the patient-centered medicine; the literature on patient-centeredness, in particular in the field of chronic disorders, will be discussed and the importance of this approach underlined; arguments about the importance of patient-centered medicine as theoretical frame founding and supporting the concept of patient engagement will be highlighted, considering that only within this medical epistemology the patient's engagement can find a full and complete expression.

Projected growth of the adult congenital heart disease population in the United States to 2050: an integrative systems modeling approach

Background

Mortality for children with congenital heart disease (CHD) has declined with improved surgical techniques and neonatal screening; however, as these patients live longer, accurate estimates of the prevalence of adults with CHD are lacking.

Methods

To determine the prevalence and mortality trends of adults with CHD, we combined National Vital Statistics System data and National Health Interview Survey data using an integrative systems model to determine the prevalence of recalled CHD as a function of age, sex, and year (by recalled CHD, we mean positive response to the question “has a doctor told you that (name) has congenital heart disease?”, which is a conservative lower-bound estimate of CHD prevalence). We used Human Mortality Database estimates and US Census Department projections of the US population to calculate the CHD-prevalent population by age, sex, and year. The primary outcome was prevalence of recalled CHD in adults from 1970 to 2050; the secondary outcomes were birth prevalence and mortality rates by sex and women of childbearing age (15–49 years).

Results

The birth prevalence of recalled CHD in 2010 for males was 3.29 per 1,000 (95 % uncertainty interval (UI) 2.8–3.6), and for females was 3.23 per 1,000 (95 % UI 2.3–3.6). From 1968 to 2010, mortality among zero to 51-week-olds declined from 170 to 53 per 100,000 person years. The estimated number of adults (age 20–64 years) with recalled CHD in 1968 was 118,000 (95 % UI 72,000–150,000). By 2010, there was an increase by a factor of 2.3 (95 % UI 2.2–2.6), to 273,000 (95 % UI 190,000–330,000). There will be an estimated 510,000 (95 % UI: 400,000–580,000) in 2050. The prevalence of adults with recalled CHD will begin to plateau around the year 2050. In 2010, there were 134,000 (95 % UI 69,000–160,000) reproductive-age females (age 15–49 years) with recalled CHD in the United States.

Conclusion

Mortality rates have decreased in infants and the prevalence of adults with CHD has increased but will slow down around 2050. This population requires adult medical systems with providers experienced in the care of adult CHD patients, including those familiar with reproduction in women with CHD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-015-0063-z) contains supplementary material, which is available to authorized users.

Certified acute care surgery programs improve outcomes in patients undergoing emergency surgery: A nationwide analysis

BACKGROUND

Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC).

METHODS

National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons' verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure.

RESULTS

A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036).

CONCLUSION

TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Exploring the relationship between age and tenure with length of disability

Background

The aging of the workforce, coupled with the changing nature of career tenure has raised questions about the impact of these trends on work disability. This study aimed to determine if age and tenure interact in relating to work disability duration.

Methods

Relationships were investigated using random effects models with 239,359 work disability claims occurring between 2008 and 2012.

Results

A 17‐day difference in the predicted length of disability was observed from ages 25 to 65. Tenure moderated the relationship between age and length of disability. At younger ages, the length of disability decreased as tenure increased, but at older age, the length of disability increased as tenure increased.

Discussion

Results indicate that although there is a relationship between length of disability and tenure, age makes a greater unique contribution to explaining variance in length of disability. Future research is needed to better understand why specifically age shows a strong relationship with length of disability and why that relationship varies with age. Am. J. Ind. Med. 58:974–987, 2015. © 2015 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals, Inc.

Comparing the Cost of Caring for Medicare Beneficiaries in Federally Funded Health Centers to Other Care Settings

OBJECTIVE

To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.

DATA SOURCES/STUDY SETTINGS

Part A and B fee-for-service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.

STUDY DESIGN

We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.

DATA COLLECTION

Data were obtained from the Centers for Medicare & Medicaid Services.

PRINCIPAL FINDINGS

Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.

CONCLUSIONS

HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.

Geographic analysis of urologist density and prostate cancer mortality in the United States

Context

Financial and demographic pressures in US require an understanding of the most efficient distribution of physicians to maximize population-level health benefits. Prior work has assumed a constant negative relationship between physician supply and mortality outcomes throughout the US and has not addressed regional variation.

Methods

In this ecological analysis, geographically weighted regression was used to identify spatially varying relationships between local urologist density and prostate cancer mortality at the county level. Data from 1,492 counties in 30 eastern and southern states from 2006–2010 were analyzed.

Findings

The ordinary least squares (OLS) regression found that, on average, increasing urologist density by 1 urologist per 100,000 people resulted in an expected decrease in prostate cancer mortality of -0.499 deaths per 100,000 men (95% CI -0.709 to -0.289, p-value < 0.001), or a 1.5% decrease. Geographic weighted regression demonstrated that the addition of one urologist per 100,000 people in counties in the southern Mississippi River states of Arkansas, Mississippi, and Louisiana, as well as parts of Illinois, Indiana, and Wisconsin is associated with decrease of 0.411 to 0.916 in prostate cancer mortality per 100,000 men (1.6–3.6%). In contrast, the urologist density was not significantly associated with the prostate state mortality in the new England region.

Conclusions

The strength of association between urologist density and prostate cancer mortality varied regionally. Those areas with the highest potential for effects could be targeted for increasing the supply of urologists, as it associated with the largest predicted improvement in prostate cancer mortality.

Multi-faceted informatics system for digitising and streamlining the reablement care model

Reablement is new paradigm to increase independence in the home amongst the ageing population. And it remains a challenge to design an optimal electronic system to streamline and integrate reablement into current healthcare infrastructure. Furthermore, given reablement requires collaboration with a range of organisations (including national healthcare institutions and community/voluntary service providers), such a system needs to be co-created with all stakeholders involved. Thus, the purpose of this study is, (1) to bring together stakeholder groups to elicit a comprehensive set of requirements for a digital reablement system, (2) to utilise emerging technologies to implement a system and a data model based on the requirements gathered and (3) to involve user groups in a usability assessment of the system. In this study we employed a mixed qualitative approach that included a series of stakeholder-involved activities. Collectively, 73 subjects were recruited to participate in an ideation event, a quasi-hackathon and a usability study. The study unveiled stakeholder-led requirements, which resulted in a novel cloud-based system that was created using emerging web technologies. The system is driven by a unique data model and includes interactive features that are necessary for streamlining the reablement care model. In summary, this system allows community based interventions (or services) to be prescribed to occupants whilst also monitoring the occupant's progress of independent living.

National dissemination of multiple evidence-based disease prevention programs: reach to vulnerable older adults

Older adults, who are racial/ethnic minorities, report multiple chronic conditions, reside in medically underserved rural areas, or have low incomes carry a high burden of chronic illness but traditionally lack access to disease prevention programs. The Chronic Disease Self-Management Program (CDSMP), A Matter of Balance/Volunteer Lay Leader (AMOB/VLL), and EnhanceFitness (EF) are widely disseminated evidence-based programs (EBP), but the extent to which they are simultaneously delivered in communities to reach vulnerable populations has not been documented. We conducted cross-sectional analyses of three EBP disseminated within 27 states throughout the United States (US) (2006-2009) as part of the Administration on Aging (AoA) Evidence-Based Disease and Disability Prevention Initiative, which received co-funding from the Atlantic Philanthropies. This study measures the extent to which CDSMP, AMOB/VLL, and EF reached vulnerable older adults. It also examines characteristics of communities offering one of these programs relative to those simultaneously offering two or all three programs. Minority/ethnic participants represented 38% for CDSMP, 26% for AMOB/VLL, and 43% for EF. Rural participation was 18% for CDSMP, 17% for AMOB/VLL, and 25% for EF. Those with comorbidities included 63.2% for CDSMP, 58.7% for AMOB/VLL, and 63.6% for EF while approximately one-quarter of participants had incomes under $15,000 for all programs. Rural areas and health professional shortage areas (HPSA) tended to deliver fewer EBP relative to urban areas and non-HPSA. These EBP attract diverse older adult participants. Findings highlight the capability of communities to serve potentially vulnerable older adults by offering multiple EBP. Because each program addresses unique issues facing this older population, further research is needed to better understand how communities can introduce, embed, and sustain multiple EBP to ensure widespread access and utilization, especially to traditionally underserved subgroups.

Health care 2020: reengineering health care delivery to combat chronic disease

Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic.

Implications of workforce and financing changes for primary care practice utilization, revenue, and cost: a generalizable mathematical model for practice management

BACKGROUND

Primary care practice transformations require tools for policymakers and practice managers to understand the financial implications of workforce and reimbursement changes.

OBJECTIVE

To create a simulation model to understand how practice utilization, revenues, and expenses may change in the context of workforce and financing changes.

RESEARCH DESIGN

We created a simulation model estimating clinic-level utilization, revenues, and expenses using user-specified or public input data detailing practice staffing levels, salaries and overhead expenditures, patient characteristics, clinic workload, and reimbursements. We assessed whether the model could accurately estimate clinic utilization, revenues, and expenses across the nation using labor compensation, medical expenditure, and reimbursements databases, as well as cost and revenue data from independent practices of varying size. We demonstrated the model's utility in a simulation of how utilization, revenue, and expenses would change after hiring a nurse practitioner (NP) compared with hiring a part-time physician.

RESULTS

Modeled practice utilization and revenue closely matched independent national utilization and reimbursement data, disaggregated by patient age, sex, race/ethnicity, insurance status, and ICD diagnostic group; the model was able to estimate independent revenue and cost estimates, with highest accuracy among larger practices. A demonstration analysis revealed that hiring an NP to work independently with a subset of patients diagnosed with diabetes or hypertension could increase net revenues, if NP visits involve limited MD consultation or if NP reimbursement rates increase.

CONCLUSIONS

A model of utilization, revenue, and expenses in primary care practices may help policymakers and managers understand the implications of workforce and financing changes.

Strategic modeling of the pediatric nurse practitioner workforce

OBJECTIVE

To assess the current pediatric nurse practitioner (PNP) workforce and to investigate the impact of potential policy changes to address forecasted shortages.

METHODS

We modeled the admission of students into nursing bachelor's programs and followed them through advanced clinical programs. Prediction models were combined with optimal decision-making to determine best-case scenario admission levels. We computed 2 measures: (1) the absolute shortage and (2) the expected number of years until the PNP workforce will be able to fully satisfy PNP demand (ie, self-sufficiency).

RESULTS

There is a forecasted shortage of PNPs in the workforce over the next 13 years. Under the best-case scenario, it would take at least 13 years for the workforce to fully satisfy demand. Our analysis of potential policy changes revealed that increasing the specialization rate for PNPs by 4% would decrease the number of years required until there are enough PNPs from 13 years to 5 years. Increasing the certification examination passing rate to 96% from the current average of 86.9% would lead to self-sufficiency in 11 years. In addition, increasing the annual growth rate of master's programs to 36% from the current maximum of 10.7% would result in self-sufficiency in 5 years.

CONCLUSIONS

Current forecasts of demand for PNPs indicate that the current workforce will be incapable of satisfying the growing demand. Policy changes can result in a reduction in the expected shortage and potentially improve access to care for pediatric patients.

Evaluating the effects of increasing physical activity to optimize rehabilitation outcomes in hospitalized older adults (MOVE Trial): study protocol for a randomized controlled trial

Background

Older adults who have received inpatient rehabilitation often have significant mobility disability at discharge. Physical activity levels in rehabilitation are also low. It is hypothesized that providing increased physical activity to older people receiving hospital-based rehabilitation will lead to better mobility outcomes at discharge.

Methods/Design

A single blind, parallel-group, multisite randomized controlled trial with blinded assessment of outcome and intention-to-treat analysis. The cost effectiveness of the intervention will also be examined. Older people (age >60 years) undergoing inpatient rehabilitation to improve mobility will be recruited from geriatric rehabilitation units at two Australian hospitals. A computer-generated blocked stratified randomization sequence will be used to assign 198 participants in a 1:1 ratio to either an ‘enhanced physical activity’ (intervention) group or a ‘usual care plus’ (control) group for the duration of their inpatient stay. Participants will receive usual care and either spend time each week performing additional physical activities such as standing or walking (intervention group) or performing an equal amount of social activities that have minimal impact on mobility such as card and board games (control group). Self-selected gait speed will be measured using a 6-meter walk test at discharge (primary outcome) and 6 months follow-up (secondary outcome). The study is powered to detect a 0.1 m/sec increase in self-selected gait speed in the intervention group at discharge. Additional measures of mobility (Timed Up and Go, De Morton Mobility Index), function (Functional Independence Measure) and quality of life will be obtained as secondary outcomes at discharge and tertiary outcomes at 6 months follow-up. The trial commenced recruitment on 28 January 2014.

Discussion

This study will evaluate the efficacy and cost effectiveness of increasing physical activity in older people during inpatient rehabilitation. These results will assist in the development of evidenced-based rehabilitation programs for this population.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000884707 (Date of registration 08 August 2013); ClinicalTrials.gov Identifier NCT01910740 (Date of registration 22 July 2013).

A longitudinal examination of anxiety disorders and physical health conditions in a nationally representative sample of U.S. older adults

BACKGROUND

There has been growing interest in the relation between anxiety disorders and physical conditions in the general adult population. However, little is known about the nature of this association in older adults. Understanding the complex relationship between these disorders can help to inform prevention and treatment strategies unique to this rapidly growing segment of the population.

METHODS

A total of 10,409 U.S. adults aged 55+ participated in Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lifetime and past-year DSM-IV anxiety, mood, and substance use disorders, and lifetime personality disorders, were assessed in both waves. Participants self-reported on whether they had been diagnosed by a healthcare professional with a broad range of physical health conditions; this study focuses on cardiovascular disease, gastrointestinal disease, and arthritis. Multivariable logistic regressions adjusted for sociodemographics, comorbid mental disorders, and number of physical health conditions assessed: (1) the relation between past-year physical conditions at Wave 1 and incident past-year anxiety disorders at Wave 2 and; (2) the relation between individual lifetime anxiety disorders at Wave 1 and incident physical conditions at Wave 2. A second set of adjusted multinomial logistic regressions examined Wave 1 sociodemographic and physical and mental health risk factors associated with incident physical condition alone, anxiety disorder alone, and comorbid anxiety and physical condition at Wave 2.

RESULTS

Past-year arthritis at Wave 1 was significantly associated with increased odds of incident generalized anxiety disorder at Wave 2. Further, any lifetime anxiety disorder and posttraumatic stress disorder at Wave 1 were significantly associated with increased odds of incident gastrointestinal disease at Wave 2. Differential sociodemographic and physical and mental health predictors were significantly associated with increased odds of incident comorbid anxiety disorder and physical conditions.

CONCLUSION

Results of the current study elucidate the longitudinal bidirectional relationships between anxiety disorders and physical health conditions in a large, nationally representative sample of older adults. These results have important implications for identifying at risk older adults, which will not only impact this growing segment of the population directly, but will also potentially lessen burden on the healthcare system as a whole.

Functional disability and ability 75-year-olds: a comparison of two Swedish cohorts born 30 years apart

OBJECTIVE

to compare the level of functional disability and involvement in leisure activities between two birth cohorts of Swedish 75-year-olds examined in 1976-77 and 2005-06.

DESIGN

cohort comparison.

SETTING AND PARTICIPANTS

representative data from the general population in Gothenburg, Sweden, examined at the age of 75 in 1976-77 (n = 744), and in 2005-06 (n = 731) with comprehensive somatic and psychiatric examinations.

MEASUREMENTS

activities of daily living (ADL); instrumental activities of daily living (IADL); a battery of self-report measures, including involvement in leisure activities, satisfaction with home-environment, social networks and self-rated health.

RESULTS

functional disability in ADL decreased between the cohorts (13.9 versus 5.6%, P < 0.001). Functional disability in IADL also decreased between the cohorts (33.4 versus 13.0%, P < 0.001). Combining ADL and IADL resulted in an overall decreased dependency, with the largest decrease seen in women (42.3 versus 15.1%, P < 0.001). Involvement in leisure activities increased between the cohorts. For example, the proportion going on international and domestic holiday travels increased (6.3 versus 16.2%, P < 0.001), and the proportion who independently drove their own car also increased (10.0 versus 53.0%, P < 0.001).

CONCLUSION

later born cohorts of 75-year-olds are less dependent in ADL and more engaged in leisure activities compared with earlier cohorts. Later born cohorts of 75-year-olds are thus better equipped to maintain a non-age-related identity compared with earlier cohorts. Our findings might serve as a reason to adopt a more positive view to ageing in a world with an increasing number of older people.

Transforming health care delivery through consumer engagement, health data transparency, and patient-generated health information

OBJECTIVE

Address current topics in consumer health informatics.

METHODS

Literature review.

RESULTS

Current health care delivery systems need to be more effective in the management of chronic conditions as the population turns older and experiences escalating chronic illness that threatens to consume more health care resources than countries can afford. Most health care systems are positioned poorly to accommodate this. Meanwhile, the availability of ever more powerful and cheaper information and communication technology, both for professionals and consumers, has raised the capacity to gather and process information, communicate more effectively, and monitor the quality of care processes.

CONCLUSION

Adapting health care systems to serve current and future needs requires new streams of data to enable better self-management, improve shared decision making, and provide more virtual care. Changes in reimbursement for health care services, increased adoption of relevant technologies, patient engagement, and calls for data transparency raise the importance of patient-generated health information, remote monitoring, non-visit based care, and other innovative care approaches that foster more frequent contact with patients and better management of chronic conditions.

Work and retirement preferences of practicing radiologists as a predictor of workforce needs

RATIONALE AND OBJECTIVES

The radiology job market has been described as highly variable, and recent practice hiring surveys predict that the number of available jobs will remain flat. Radiologists may be working more hours and retiring later than desired, activities that influence overall job availability. A national survey was performed to determine the desired work rate and retirement preferences of practicing radiologists, and the responses are used to estimate current and potential future work output and future workforce needs.

MATERIALS AND METHODS

Practicing radiologists were surveyed regarding current and preferred work level and desired and expected retirement age. A model incorporating these preferences and stratified by age was developed using survey responses and American Medical Association full-time equivalent (FTE) estimates. Available FTE radiologists are estimated under four scenarios from 2016 to 2031 in 5-year intervals.

RESULTS

The model predicts a total of 26,362 FTE radiologists available in 2011, which corresponds to previous estimates. Participants reported working more hours and expecting to retire later than desired, with younger radiologists and women reporting the greatest desired decrease in FTE hours worked. Under each scenario, there is an initial FTE availability in 2016 ranging from 21,156 to 24,537, which increases to between 27,753 and 31,435 FTE by 2031 depending on work rate and retirement patterns.

CONCLUSIONS

Practicing radiologists report that they currently work more hours than desired and expect to retire later than they would prefer. If radiologists changed current personal work rate and expected retirement age to meet these preferences, there would be an immediate shortage of FTE radiologists continuing until at least 2020 assuming no other workforce needs changes.

A new paradigm is needed for medical education in the mid-twenty-first century and beyond: are we ready?

The twentieth century witnessed profound changes in medical education. All these changes, however, took place within the existing framework, suggested by Flexner a century ago. The present paper suggests that we are approaching a singularity point, where we shall have to change the paradigm and be prepared for an entirely new genre of medical education. This suggestion is based upon analysis of existing and envisaged trends: first, in technology, such as availability of information and sophisticated simulations; second, in medical practice, such as far-reaching interventions in life and death that create an array of new moral dilemmas, as well as a change in patient mix in hospitals and a growing need of team work; third, in the societal attitude toward higher education. The structure of the future medical school is delineated in a rough sketch, and so are the roles of the future medical teacher. It is concluded that we are presently not prepared for the approaching changes, neither from practical nor from attitudinal points of view, and that it is now high time for both awareness of and preparation for these changes.

Patterns of Change in ACGME-Accredited Residency Programs and Positions: Implication for the Adequacy of GME Positions and Supply of Physicians in the United States

BACKGROUND

Recent studies suggest that the supply of primary care physicians and generalist physicians in other specialties may be inadequate to meet the needs of the US population. Data on the numbers and types of physicians-in-training, such as those collected by the Accreditation Council for Graduate Medical Education (ACGME), can be used to help understand variables affecting this supply.

OBJECTIVE

We assessed trends in the number and type of medical school graduates entering accredited residencies, and the impact those trends could have on the future physician workforce.

METHODS

Since 2004, the ACGME has published annually its data on accredited institutions, programs, and residents to help the graduate medical education community understand major trends in residency education, and to help guide graduate medical education policy. We present key results and trends for the period between academic years 2003-2004 and 2012-2013.

RESULTS

The data show that increases in trainees in accredited programs are not uniform across specialties, or the types of medical school from which trainees graduated. In the past 10 years, the growth in residents entering training that culminates in initial board certification ("pipeline" specialties) was 13.0%, the number of trainees entering subspecialty education increased 39.9%. In the past 5 years, there has been a 25.8% increase in the number of osteopathic physicians entering allopathic programs.

CONCLUSIONS

These trends portend challenges in absorbing the increasing numbers of allopathic and osteopathic graduates, and US international graduates in accredited programs. The increasing trend in subspecialization appears at odds with the current understanding of the need for generalist physicians.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind

BACKGROUND

Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species.

OBJECTIVE

We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care.

INTERVENTION

We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations.

ANTICIPATED OUTCOMES

New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities.

CONCLUSIONS

The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

ICU service in Taiwan

Background

The aim of the study was to understand the current status of intensive care unit (ICU) in order to optimize the resources achieving the best possible care.

Methods

The study analyzed the status of ICU settings based on the Taiwan National Health Insurance database between March 2004 and February 2009.

Results

A total of 1,028,364 ICU patients were identified. The age was 65 ± 18 years, and 61% of the patients were male. The total ICU bed occupancy rate was 83.8% which went up to 87.3% during winter. The ICU bed occupancy was 94.4% in major medical centers. The ICU stay was 6.5 ± 0.5 days, and the overall ICU mortality rate was 20.2%. The hospital stay was 16.4 ± 16.8 days, and the average cost of total hospital stay was approximately US$5,186 per patient.

Conclusions

The rate of ICU bed occupancy was dependent on seasonal changes, and it reached near full capacity in major medical centers in Taiwan. The ICU beds were distributed based on the categories of hospitals in order to achieve a reasonable cost efficiency. ICU faces many challenges to maintain and improve quality care because of the increasing cost of state-of-the-art technologies and dealing with aging population.