L. Gary Hart, PhD

Phone: 520.626.6258
Fax: 520.626.3101
E-mail: garyhart@email.arizona.edu

Rural Health Office, Mel & Enid Zuckerman College of Public Health
University of Arizona
Drachman Hall, A247
1295 North Martin Avenue
Tucson, AZ 85724

Current Projects

Introduction to and Description of the 2004 (Version 2) Rural-Urban Commuting Areas (RUCAs)
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Defining rural, Health policy
This project's deliverable is an introduction to the methodology and uses of the new version of the Rural-Urban Commuting Areas (RUCAs). The description will include examples of RUCA uses and its strengths and shortcomings.

National Study of Available Information on H1-B, J-1 and other International Medical Graduate Information
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: International Medical Graduates (IMGs), J-1 Visa Waiver, Workforce
This project is examining sources of data and information on various pathways by which international medical graduates can enter into the U.S. physician workforce, focusing on H1-B visas and J-1 visas.

National Study of Rural-Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Chronic diseases and conditions, Medicare
To understand disparities in care among rural and urban Medicare beneficiaries, data from Medicare's Durable Medical Equipment (DME) files were used to assess rural/urban variation in the home use of supplemental oxygen.

Completed Projects

Access to Physician Care for the Rural Medicare Elderly, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Aging, Chronic diseases and conditions, Health services, Medicare, Physicians, Poverty
This study described where Medicare beneficiaries in five states obtain their health care, how far they travel for that care, and the mix of physician specialties from which they obtain ambulatory care. Special attention was paid to beneficiaries who have dual Medicare-Medicaid status, who reside in poorer income areas, and who live in designated Health Professional Shortage Areas.

Ambulatory Care and the Rural Elderly, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Aging, Chronic diseases and conditions, Health services

Chartbook of Family Practice Graduate Medical Education Programs in Rural America, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Physicians, Workforce
Little is known about the volume, location, and types of rural training for family physicians. This project will produce a chartbook that makes previously unreported information about family physician residency directors more fully available to medical educators and other policymakers.

Demographics, Education and Practice Characteristics of Nurse Practitioners in Washington, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: Mid-level practitioners, Nurses, Workforce
This 2003 survey of nurse practitioners in Washington State examines how many have been educated in-state, how many work full vs. part-time, the extent to which they provide care to underserved and rural populations, their use of newly acquired expanded drug authority, and other characteristics of their clinical practices.

Evaluation of Alternative New Health Professional Shortage Area Designation Criteria, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Primary Health Care (BPHC)
Topic: Workforce

Evaluation of Washington State Shortage Designations, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Workforce

Historical Trends in Physician Assistant Education and their Contribution to Primary Health Care for Rural and Underserved Populations in the U.S.
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: Legislation and regulation, Mid-level practitioners, Workforce
This study describes the historical development of the physician assistant (PA) profession since 1967, with special emphasis on the demography of the PA population, the PA regulatory environment, the evolution of specialty roles, the emergence of practice location patterns, and the contribution by PAs to primary care for rural and underserved populations.

International Medical Graduates: Changes in Characteristics Over Time, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: International Medical Graduates (IMGs), Workforce
This study describes changes over time in international medical graduate’s (IMG’s) country of education, demographics, type of practice, specialty, and propensity to practice in needy locations from 1981 to 2001.

Medicare Bonus Payments for Physician Care in Health Professional Shortage Areas, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health care financing, Medicare, Physicians

National Rural General Surgeon Project, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Physicians, Workforce

National Rural Hospital Flexibility Program Tracking Project, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program

Pacific Basin Health Workforce and Training Project, Lead researcher
Research center: WWAMI Rural Health Research Center
Funders: Bureau of Health Professions, Bureau of Primary Health Care (BPHC)
Topic: Workforce

Rural Health Center Expansion and Recruitment Survey, Lead researcher
Research centers: South Carolina Rural Health Research Center, WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Workforce
This collaborative project between WWAMI and the South Carolina Rural Health Research Centers examined and described the current staffing needs of rural health centers (HC), ascertained the staffing, recruitment, and retention issues that HC CEOs regard as most critical; distinguish edhow issues differ between CEOs contemplating development of expansion sites versus those who are not; and described how these findings correlate with the literature and current national supply projections for the categories of health professions needed by the HCs.

Rural-Urban Commuting Area (RUCA) Development Project: Demographic Description and Frontier Enhancement, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Defining rural, Frontier health
This project augments the initial RUCA work by producing and describing the base 1998 demography of the RUCA code areas, creating quality state maps of the RUCA codes, and making this information and the codes easily available on the Web.

Sources and Distribution of International Medical Graduates (IMGs), Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Bureau of Health Professions
Topics: International Medical Graduates (IMGs), Workforce
International medical graduates (IMGs - physicians educated in medical schools other than in the U.S. and Canada) account for nearly 25% of the nation’s practicing physicians, and provide considerable amounts of care in rural areas. The University of Washington Center for Health Workforce Studies has conducted a series of studies about the sources and distribution of IMGs in the U.S.

State Rural Health Workforce Monograph, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Physicians, Workforce

The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Physicians, Women, Workforce
While women are becoming an increasingly large percentage of the graduates of medical schools, they are much less likely to locate their practices in rural towns. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future.

Validation of Commuting Area Designations for the Elderly, Lead researcher
Research center: WWAMI Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Aging, Defining rural

Publications

• 2005 Physician Supply and Distribution in Rural Areas of the United States (Full Report)
  Author(s): Meredith A. Fordyce, Frederick M. Chen, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Physicians, Workforce
  Date: 11 / 2007
  This study describes the 2005 supply and distribution of physicians (including osteopathic physicians and international medical graduates) with particular emphasis on generalists in rural areas. Results indicate variability in the rural-urban distribution of physicians, with generalist physicians playing prominent roles in rural areas.
• 2005 Physician Supply and Distribution in Rural Areas of the United States (Project Summary)
  Author(s): Meredith A. Fordyce, Frederick M. Chen, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Physicians, Workforce
  Date: 11 / 2007
  This study describes the 2005 supply and distribution of physicians (including osteopathic physicians and international medical graduates) with particular emphasis on generalists in rural areas. Results indicate variability in the rural-urban distribution of physicians, with generalist physicians playing prominent roles in rural areas.
• Access to Maternity Care in Rural Washington: Its Effect on Neonatal Outcomes and Resource Use
  Author(s): Thomas S. Nesbitt, Eric H. Larson Roger A. Rosenblatt, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Children, Health services, Maternal and child health
  Citation: American Journal of Public Health, 87(1), 85-90
  Date: 01 / 1997
  Compares birth outcomes for areas with poor health care access to those with adequate health care access in rural Washington state.
• Access to Specialty Health Care for Rural American Indians in Two States
  Author(s): Baldwin LM, Hollow WB, Casey S, Hart LG, Larson EH, Moore K, Lewis E, Andrilla CHA, Grossman DC
  Research center: WWAMI Rural Health Research Center
  Topics: American Indians and Alaska Natives, Health services, Minority health
  Citation: Journal of Rural Health 24(3), 269-278
  Date: 2008
  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. This study outlines the examination of specialty service access among rural Indian populations in two states. Results indicate that 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 Specialty Health Care for Rural American Indians: Provider Perceptions in Two States
  Author(s): Laura-Mae Baldwin, Waler B. Hollow, Susan Casey, L. Gary Hart, Eric H. Larson, Kelly Moore, Ervin Lewis, David C. Grossman
  Research center: WWAMI Rural Health Research Center
  Topics: American Indians and Alaska Natives, Health services, Minority health, Physicians
  Report Number: Working Paper No. 78
  Date: 10 / 2004
  Examines access to specialty services among rural Indian populations in Montana and New Mexico, based on a survey sent to primary care providers addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services. Report available upon request by contacting rhrc@fammed.washington.edu.
• Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas
  Author(s): Leighton Chan, L. Gary Hart, Thomas C. Ricketts III, Shelli K. Beaver
  Research center: WWAMI Rural Health Research Center
  Topics: Medicare, Physicians
  Citation: Journal of Rural Health, 20(2), 109-117
  Date: 2004
  The Medicare Incentive Payment (MIP) program provides a 10 percent bonus payment to physicians who treat patients in Health Professional Shortage Areas (HPSAs). This paper examines the experience of five states (Alaska, Idaho, North Carolina, South Carolina, and Washington) with the Medicare Incentive Payment (MIP) program. This study determines the program's expenditures, utilizations, and which types of physicians received payments. Results show that physicians eligible for the bonus payments often did not claim them, and physicians who likely did not work in approved HPSA sites, claimed the bonus payments and received them.
• Barriers to Autonomous Practice
  Author(s): Louise Kaplan, Marie-Annette Brown, Holly Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Nurses, Pharmacy and prescription drugs, Workforce
  Citation: Nurse Practitioner, 31(1), 57-63
  Date: 01 / 2006
  Describes a study of the impact of a Washington State law changing nurse practitioners (NPs) prescribing authority. The study examined whether prescribing with indirect physician involvement eliminated barriers to practice, the extent to which the law created barriers to prescribing certain drugs, and compared NPs' experiences prescribing or providing controlled substances before and after implementation of the current law.
• Changing Geography of Americans Graduating from Foreign Medical Schools
  Author(s): Karin E. Johnson, Amy Hagopian, Catherine Veninga, Meredith A. Fordyce, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Workforce
  Report Number: Working Paper No. 96
  Date: 03 / 2005
  While only 4 percent of U.S. physicians known to have been born in the United States attended medical school in foreign countries, these physicians represent at least 11 percent of the physicians known as international medical graduates (IMGs). Americans continue to pursue medical education abroad. The majority of United States-born IMGs (USIMGs) trained in just a dozen countries and at just two-dozen medical schools. Several foreign medical schools have contributed more graduates to the current practice pool than U.S. medical schools. Currently practicing older USIMGs were most likely to have attended medical school in Europe and Mexico, while more recent USIMGs are most likely to have attended medical school in Mexico and the Caribbean. U.S.-born students comprise a large percentage of the total IMGs from those countries. Offshore medical schools continue to train large numbers of Americans, but in smaller numbers than in the 1980s. Schools in European countries are less prominent and relatively new schools in Caribbean countries have become more popular.
• Changing Geography of Americans Graduating from Foreign Medical Schools
  Author(s): Karin Johnson, Amy Hagopian, Catherine Veninga, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Workforce
  Citation: Academic Medicine, 81(2), 179-184
  Date: 02 / 2006
  Reports the results of a study of U.S.-born international medical graduates, analyzing changes in their numbers and countries of training from the 1960s and before until the early 2000s.
• Characteristics of Registered Nurses in Rural Versus Urban Areas: Implications for Strategies to Alleviate Nursing Shortages in the United States
  Author(s): Susan M. Skillman, Lorella Palazzo, David Keepnews, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Nurses, Workforce
  Citation: Journal of Rural Health, 22(2), 151-157
  Date: 2006
  Provides results of a study comparing characteristics of rural and urban registered nurses (RNs) in the United States using data from the 2000 National Sample Survey of Registered Nurses. RNs in 3 types of rural areas are examined using the rural-urban commuting area taxonomy.
• Characteristics of Registered Nurses in Rural vs. Urban areas: Implications for Strategies to Alleviate Nursing Shortages in the United States
  Author(s): Susan M. Skillman, Lorella Palazzo, David Keepnews, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Nurses, Workforce
  Report Number: Working Paper No. 91
  Date: 01 / 2005
  Compares characteristics of rural and urban registered nurses (RNs) in the United States using national survey data, and examined certain characteristics of rural RNs that should be considered in developing strategies to alleviate nursing shortages. Such strategies require understanding of rural RNs' work, education, and commuting patterns. If higher wages attract and retain nurses, and urban employers are better positioned than rural employers to raise wages, this policy could draw larger numbers of RNs from rural to urban settings. A "one size fits all" approach to resolving nurse shortages may benefit one geographic area type at the expense of others.
• Characterizing the General Surgery Workforce in Rural America
  Author(s): Matthew J. Thompson, Dana Christian Lynge, Eric H. Larson, Pantipa Tachawachira, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Report Number: Working Paper No. 77
  Date: 05 / 2004
  General surgeons form a crucial component of the medical workforce in rural areas of the United States. Analysis of the data suggests that the general surgical workforce has not kept pace with the rising population, and that the number of general surgeons in most rural areas of the U.S. will decline further. Report available upon request by contacting rhrc@fammed.washington.edu.
• Characterizing the General Surgery Workforce in Rural America
  Author(s): Matthew J. Thompson, Dana Christian Lynge, Eric H. Larson, Pantipa Tachawachira, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: Archives of Surgery, 140(1), 74-79
  Date: 01 / 2005
  Describes the rural general surgical workforce. Discusses the potential impact of its demographic characteristics on rural access to surgical services in the future.
• Clearing the Path to Medical School for American Indians and Alaska Natives: New Strategies
  Author(s): Walter B. Hollow, Apanakhi Buckley, Davis G. Patterson, Polly M. Olsen, Joycelyn Dorscher, Rustem Medora, Lori Morin, R. Steven Padilla, Jerry Tahsequah, Laura-Mae Baldwin
  Research center: WWAMI Rural Health Research Center
  Topics: American Indians and Alaska Natives, Physicians, Workforce
  Report Number: Working Paper No. 101
  Date: 01 / 2006
  Two recent studies examining recruitment and retention of American Indians and Alaska Natives (AI/ANs) in medical school identified significant challenges in the pursuit of a medical career by AI/AN students: the academic rigor of medical school, the needs of their communities and families, financial concerns, feelings that their perspectives on healing and spirituality were excluded from medical school, and the paucity of role models and mentors, especially those who shared their culture. Using the results of this research and their experience conducting programs to support AI/ANs pursuing health professions, the authors recommend several strategies for improving recruitment and retention of AI/AN medical students. These strategies include: 1. providing role models, advisors, and mentors; 2. providing early research opportunities by involving AI/AN communities in research on Native health issues; 3. anticipating students' traditional Native spiritual practices; 4. providing professional socialization opportunities for faculty and AI/AN medical students; 5. creating and implementing rigorous curricula that include indigenous perspectives; and 6. developing a pro-diversity institutional mission statement to inform admissions policies. The authors identify governmental and nongovernmental organizations in a position to fund and implement these strategies, as well as a list of resources. Collaboration with AI/AN individuals, organizations, and communities is critical to this effort but not a familiar role for most academic medical centers; suggestions for cross-cultural outreach and collaboration are provided.
• Contribution of Nurse Practitioners and Physician Assistants to Generalist Care in Underserved Areas of Washington State
  Author(s): Eric H Larson, Lorella Palazzo, Bobbi Berkowitz, Michael J Pirani, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Nurses, Workforce
  Citation: Health Services Research, 38(4), 1033-1050
  Date: 08 / 2003
  Uses productivity data from the non-physician clinician (NPC) and physician populations in Washington State to assess the contribution to generalist care made by NPCs, giving special attention to the role of NPCs in rural and underserved areas and the role of women NPCs in the female provider population. Overall, generalist NPCs make up 23.4 percent of the generalist provider population and perform about 21 percent of the generalist outpatient visits in Washington State. NPC contribution is higher in rural areas of the state and a bit lower in urban areas. In rural areas, female physicians provided only 49.3 percent of the visits by female providers; female NPCs provided the remaining 50.3 percent. In urban areas, female physicians provided about 63.5 percent; female NPCs provided 46.5 percent. NPCs made similar contributions to total care in rural HPSAs compared to rural non-shortage areas, though physician assistants appear to contribute somewhat more care in HPSAs with severe shortages of providers. The results suggest that accurate and meaningful estimates of available generalist care must take into account the contribution of NPCs.
• Do International Medical Graduates "Fill the Gap" in Rural Primary Care in the United States?
  Author(s): Matthew J. Thompson, Amy Hagopian, Meredith A. Fordyce, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Workforce
  Report Number: Working Paper No. 106
  Date: 2006
  Compares the practice locations of international medical graduates (IMGs) and U.S. medical graduates (USMGs) in primary care specialties. Report available upon request by contacting rhrc@fammed.washington.edu.
• Evaluation of Alternative Health Professional Shortage Area (HPSA) Definitions in Washington State
  Author(s): C. Holly A. Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Workforce
  Date: 08 / 2006
  Technical brief describing the differences in Health Professional Shortage Area (HPSA) designation status of the 124 Health Service Areas (HSAs) in Washington State that result when the current designation system is used and provider counts versus provider full-time equivalencies (FTEs) are used.
• 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?
  Author(s): Roger A Rosenblatt, R Schneeweiss, L Gary Hart, S Casey, C Holly Andrilla, Fredercik M Chen
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Report Number: No. 69
  Date: 03 / 2002
  Determines how much rural family practice training is taking place in the United States. Among the results are that only 33 family medicine residency programs (7.4 percent) are located in rural areas and most of the training sponsored by these programs occurs in rural areas. On the other hand, while more than one-third of the urban programs listed rural training as an important part of their mission, only 2.3 percent of the training they supported took place in rural areas. For the nation as a whole, only 7.5 percent of family medicine residency training occurred in rural areas despite the fact that 22.3 percent of the U.S. population lives in rural places. The report concludes that to the extent that there is a link between the place of training and future practice, the lack of rural training contributes to the shortage of rural physicians. Furthermore, unless significant efforts are made to increase rural residency training, rural physician shortages are likely to persist.
• Gender-Related Factors in the Recruitment of Generalist Physicians to the Rural Northwest
  Author(s): Katherine E Ellsbury, Laura-Mae Baldwin, Karin E Johnson, SJ Runyan, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women
  Report Number: No. 62
  Date: 02 / 2001
  Examines differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identifies the practice arrangements that attracted female generalist physicians to rural areas. Findings include: women were more likely than men to have been influenced in practice choice by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of childcare; women were more highly influenced by the interpersonal aspects of recruitment; and men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. Findings indicate that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues in the recruiting process if they want to achieve a gender-balanced physician workforce.
• Geographic Access to Health Care for Rural Medicare Beneficiaries
  Author(s): Leighton Chan, L. Gary Hart, David C. Goodman
  Research center: WWAMI Rural Health Research Center
  Topics: Health services, Medicare
  Report Number: Working Paper No. 97
  Date: 04 / 2005
  This study looked at where Medicare beneficiaries of five states obtain their care, how far they travel for that care, and the mix of physician specialties from whom they obtain their ambulatory care. Findings from this study suggest that rural residents do not rely on urban areas for the majority of their care. Those living in small and isolated rural areas have decreased geographic access to health care providers, particularly specialists, and rely heavily on generalists for the majority of their care. Additionally, results of the study suggest that these individuals have few visits overall and must travel longer distances to access certain types of care. These findings have policy implications for geographic reimbursement differentials, telehealth networks, and graduate medical education. Report available upon request by contacting rhrc@fammed.washington.edu.
• Geographic Access to Health Care for Rural Medicare Beneficiaries
  Author(s): Leighton Chan, L. Gary Hart, David C. Goodman
  Research center: WWAMI Rural Health Research Center
  Topics: Health services, Medicare, Physicians
  Citation: Journal of Rural Health 22(2),140-146
  Date: 2006
  Describes the results of a study comparing the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington.
• Geographic and Demographic Dimensions of the Adoption of a Health Workforce Innovation: Physician Assistants in the United States, 1967-2000
  Author(s): Eric H. Larson, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Workforce
  Report Number: Working Paper No. 105
  Date: 12 / 2005
  Describes changes in the demography and distribution of the physician assistant (PA) population between 1967 and 2000, as well as the spread of PA training programs.
• Health Center Expansion and Recruitment Survey 2004: Results by Health and Human Services Regions and Health Center Geography
  Author(s): C. Holly A. Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Federally Qualified Health Centers (FQHCs), Workforce
  Report Number: Technical report
  Date: 03 / 2007
  Reports findings from the national study of health centers staffing, recruitment and retention. Provides information by HHS region, urban and rural geography, and national overall estimates. Includes 118 graphs of selected survey results.
• Health Departments' Use of International Medical Graduates in Physician Shortage Areas
  Author(s): Amy Hagopian, Matthew J. Thompson, Emily Kaltenbach, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), J-1 Visa Waiver, Workforce
  Citation: Health Affairs, 22(5), 241-249
  Date: 2003
  Describes results of a survey of program administrators of the Conrad State 20 Program, which places international medical graduates (IMGs) on J-1 visas in health professional shortage areas (HPSAs). Problems reported include unfair working conditions and compensation for physicians. Federal immigration agencies were reported to be unresponsive and difficult. Employers seem to be more satisfied than physicians with the program.
• Heavy And Binge Drinking In Rural America: A Comparison Of Rural And Urban Counties From 1995/1997 Through 1999/2001
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Substance abuse
  Report Number: Working Paper No. 95
  Date: 02 / 2005
  Assesses the prevalence of, and recent trends in, alcohol use among adults 18 years and older in rural areas of the United States. It uses a random digit telephone survey method to gather information on alcohol use among adults in 49 states and the District of Columbia that participated in the Behavioral Risk Factor Surveillance System. The paper finds that heavy drinking was highest and increasing in urban areas, but that binge drinking was greater in rural areas. It recommends tailoring interventions specifically to meet the needs of rural residents. Report available upon request by contacting rhrc@fammed.washington.edu.
• How International Medical Graduates Enter U.S. Graduate Medical Education or Employment
  Author(s): Karin E. Johnson, Emily Kaltenbach, Kenneth Hoogstra, Matthew J. Thompson, Amy Hagopian, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), J-1 Visa Waiver, Workforce
  Report Number: Working Paper No. 76
  Date: 2003
  Provides an overview of the steps that must occur for an international medical graduate (IMG) to come to the United States to practice medicine. Describes how long and by what means IMGs holding temporary visas can remain in the United States, with detailed coverage of the State 30/Conrad J-1 visa waiver program.
• How Many Physicians Can a Rural Community Support? A Practice Income Potential Model for Washington State
  Author(s): George E Wright, C Holly Andrilla, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Report Number: No. 45
  Date: 04 / 2001
  Addresses the ability of smaller and underserved rural communities to financially support needed physicians. Reports on an experimental simulation model that projects potential practice income for primary care physicians in rural communities of Washington State. Finds that the distribution of physicians follows predicted economic potential. Surprisingly, the types of rural communities most likely to have fewer physicians are not small isolated towns, but larger communities with above average population growth, closer proximity to metro areas and somewhat lower average family incomes. Towns in HPSAs were predominantly constrained by demand deficits. To overcome demand barriers, continuous subsidies such as enhanced Medicare payments for certified Rural Health Clinics or 10 percent Medicare supplemental payments for care provided in a HPSA could be offered. Signing-bonus approaches may help overcome initial reluctance to practice in rural areas where demand is sufficient to support long-term retention.
• Improving the Quality of Outpatient Care for Older Patients with Diabetes: Lessons from a Comparison of Rural and Urban Communities
  Author(s): Roger A. Rosenblatt, Laura-Mae Baldwin, Leighton Chan, Meredith A. Fordyce, Irl B. Hirsch, Jerry P. Palmer, George E. Wright, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Aging, Chronic diseases and conditions, Quality
  Citation: Journal of Family Practice, 50(8), 676-680
  Date: 08 / 2001
  Compares the quality of diabetic care received by patients in rural and urban communities in Washington State. Among the findings: Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Concludes that large rural towns may provide the best conditions for high-quality care-growing communities that serve as regional referral centers and have an adequate, but not excessive, supply of generalist and specialist physicians.
• International Medical Graduate Physicians in the U.S.: Changes Since 1981
  Author(s): L. Gary Hart, Susan M. Skillman, Amy Hagopian, Meredith A. Fordyce, Matthew J. Thompson, Thomas R. Konrad
  Research center: WWAMI Rural Health Research Center
  Topics: International Medical Graduates (IMGs), Workforce
  Report Number: Working Paper No. 102
  Date: 03 / 2005
  The U.S. relies on international medical graduates (IMGs) to provide a significant portion of the country's health care, including generalist care and service to underserved populations. Understanding the trends in IMG migration and practice is important for determining how best to train an adequate supply of physicians with appropriate skills for the U.S. Key findings show that since 1981, India, the Philippines, Mexico and the Republic of Korea have remained leading countries in which IMGs in the U.S. attended medical school, and most IMGs are located in 10 U.S. states. Relatively fewer IMGs are now working in hospitals than 20 years ago. Currently IMGs are only a little more likely to be generalists than U.S. medical school graduates (USMGs).IMGs have remained less likely than USMGs to practice in rural areas, but among rural physicians, a greater proportion of IMGs practice in Health Professional Shortage Areas than of USMGs.
• Modeling the Mental Health Workforce in Washington State: Using State Licensing Data to Examine Provider Supply in Rural and Urban Areas
  Author(s): Laura-Mae Baldwin, Miriam M. Patanian, Eric H. Larson, Denise M. Lishner, Larry B. Mauksch, Wayne J. Katon, Edward Walker, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Mental health, Workforce
  Citation: Journal of Rural Health, 22(1), 50-8
  Date: 2006
  The authors sought to identify mental health shortage areas using existing licensing and survey data, and found that notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio. They concluded that states gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.
• National Study of Lifetime Asthma Prevalence and Trends in Metro and Non-Metro Counties, 2000-2003 (Full Report)
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Chronic diseases and conditions
  Report Number: Working Paper No. 108
  Date: 01 / 2007
  Reports the findings of a study of the prevalence of and recent trends in asthma among adults residing in metropolitan and non-metropolitan counties in the United States. In 2003, the adjusted prevalence of lifetime asthma diagnosis was 12.0 percent for metropolitan counties and 11.0 percent for non-metropolitan counties (p < 0.001). Prevalence of lifetime asthma diagnosis trended upwards across the rural-urban spectrum between 2000 and 2003, and states with the highest 2003 prevalence and the greatest increase in prevalence among non-metropolitan residents were concentrated in the West Census region (e.g., Arizona, California, Oregon and Washington). Asthma prevalence in non-metropolitan counties was highest for those aged 18 to 34 (15.9%), the unemployed (13.5%), American Indians (12.7%) and women (12.4%).
• National Study of Obesity Prevalence and Trends by Type of Rural County
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, Anthony F. Jerant, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Obesity
  Citation: Journal of Rural Health, 21(2), 140-148
  Date: 2005
  To estimate the prevalence of and recent trends in obesity among US adults residing in rural locations, the authors analyzed data from the Behavioral Risk Factor Surveillance System for 1994-1996 and 2000-2001and found that in 2000-2001 the prevalence of obesity was 23.0% for rural adults and 20.5% for their urban counterparts, representing increases of 4.8% and 5.5%, respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties in Louisiana, Mississippi, and Texas; obesity prevalence increased for rural residents in all states but Florida over the study period. African Americans had the highest obesity prevalence of any group, up to 31.4% in rural counties adjacent to urban counties.
• Obesity Prevalence In Rural Counties: A National Study
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, Anthony F. Jerant, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Obesity, Rural statistics and demographics
  Report Number: Working Paper No. 87
  Date: 01 / 2004
  Using a random-digit telephone survey of adults aged 18 and older residing in states participating in the Behavioral Risk Factor Surveillance System in 1994-96 and 2000-2001, researchers found that the prevalence of obesity was 23 percent for rural adults and 20.5 percent for urban adults. This finding represents increases of 4.8 percent and 5.5 percent, respectively. The highest obesity prevalence occurred in rural counties of Mississippi, Texas, and Louisiana. Only Rhode Island and Colorado had rural counties that met the Healthy People 2010 goal of a maximum of 15 percent obese for adults. Report available on request.
• Pathways to Rural Practice: A Chartbook of Family Medicine Residency Training Locations and Characteristics
  Author(s): L. Gary Hart, Denise M. Lishner, Eric H. Larson, Frederick M. Chen, C. Holly A. Andrilla, Thomas E. Norris, Ronald Schneeweiss, Tim M. Henderson, Roger A. Rosenblatt
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Citation: Seattle, WA: WWAMI Rural Health Research Center, University of Washington.
  Date: 08 / 2005
  Discusses characteristics and geographic locations of family medicine residency programs' rural locations, types of rural family medicine training by location, and rural mission of family medicine residencies.
• Perinatal and Infant Health Among Rural and Urban American Indians/Alaska Natives
  Author(s): Laura-Mae Baldwin, David C. Grossman, Susan Casey, Walter Hollow, Jonathan R. Sugarman, William L. Freeman, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: American Indians and Alaska Natives, Children, Maternal and child health, Rural statistics and demographics
  Citation: American Journal of Public Health, 92(9), 1491-1497
  Date: 09 / 2002
  Provides a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health.
• Prevalence And Trends In Smoking: A National Rural Study
  Author(s): Mark P. Doescher, J. Elizabeth Jackson, Anthony F. Jerant, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Substance abuse
  Report Number: Working Paper No. 85
  Date: 12 / 2003
  Using data from the Behavioral Risk Factor Surveillance System, the research showed that the prevalence of smoking between 1994-1996 and 2000-2001 did not change substantially for the United States as a whole. The prevalence of smoking for rural residents decreased by more than 2 percent in six states (CA, CT, MD, NC, TN, UT). However, it increased by 2 percent or more in ten states. Report available on request.
• Prevalence and Trends in Smoking: A National Rural Study
  Author(s): Mark P. Doescher, J. Elizabeth Jackson, Anthony Jerant, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Minority health, Substance abuse
  Citation: Journal of Rural Health, 22(2), 112-118
  Date: 2006
  Reports the results of a study to estimate the prevalence of and recent trends in smoking among adults by type of rural location and by state.
• Problem Drinking: Rural and Urban Trends in America 1995/97 to 2003
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Substance abuse
  Citation: Preventive Medicine, 43(2), 122-124
  Date: 2006
  Examines recent trends in heavy and binge drinking in urban counties and three types of rural counties.
• Production of Rural Female Generalists by U.S. Medical Schools
  Author(s): Katherine E Ellsbury, Mark P Doescher, L Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Women, Workforce
  Date: 05 / 1999
  Compares the production of rural female generalists among medical schools. Data from the 1996 AMA Physician Masterfile for the 1988-96 graduate cohort were analyzed to compare the production of rural female generalists by medical school. Outcome measures included total number and percentage of rural female generalist graduates of each school. Only a few schools contribute most of ht erural female generalists. These schools' admissions policies, curricula, extracurricular programs, and career advising efforts may serve as models of schools who make it a priority to encourage more of their female graduates to enter rural practice.
• Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)
  Author(s): C. Holly A. Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Federally Qualified Health Centers (FQHCs), Workforce
  Date: 11 / 2006
  Presents a subset of the findings from the larger national study of Federally Qualified Health Center (FQHC) staffing needs of FQHCs located in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) overall and by urban and rural geography.
• Retail Pharmacies in Washington State: Results of the 2003 Workforce Survey
  Author(s): Susan M. Skillman, L. Gary Hart, Elise Bowditch, Beth A. Kirlin
  Research center: WWAMI Rural Health Research Center
  Topics: Pharmacy and prescription drugs, Workforce
  Report Number: Working Paper No. 100
  Date: 12 / 2004
  Researchers surveyed retail pharmacies in Washington to estimate the demand for pharmacists, as well as pharmacy technicians and administrative/clerical staff, and to describe the impact of implementation of the Health Insurance Portability and Accountability Act (HIPAA) on retail pharmacies. Combining the results of this survey with the estimates from a survey of pharmacist vacancies in the state's hospitals, 403 pharmacists were needed statewide for retail and hospital pharmacies in 2003-2004. Pharmacy schools in Washington graduated 180 pharmacists in 2003, which was not enough to fill all of the vacancies across the state.
• Role of International Medical Graduates in America's Small Rural Critical Access Hospitals
  Author(s): Amy Hagopian, Matthew J. Thompson, Emily Kaltenbach, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, International Medical Graduates (IMGs), Workforce
  Citation: Journal of Rural Health, 20(1), 52-58
  Date: 2004
  Descriptive report presenting the roles and characteristics of foreign-born international medical graduates (IMGs) in Critical Access Hospital (CAH) facilities and the opinions of the CEOs about these practitioners.
• Rural Definitions for Health Policy and Research
  Author(s): L. Gary Hart, Eric H. Larson, Denise M. Lishner
  Research center: WWAMI Rural Health Research Center
  Topics: Defining rural, Health policy
  Citation: American Journal of Public Health, 95(7), 1149-1155
  Date: 07 / 2005
  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.
• Rural Dental Practice: A Tale of Four States (Full Report)
  Author(s): C. Holly A. Andrilla, Denise M. Lishner, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Dental health
  Report Number: Working Paper No. 107
  Date: 03 / 2006
  Reports the findings of a study investigating rural dentist issues, such as demography, training, practice characteristics, staff, and job satisfaction, in Alabama, California, Maine, and Missouri. Generally, dentists and their work patterns were similar across the four states. Dentist practices varied dramatically across states regarding staffing patterns. Vacancy rates for dental hygienists varied greatly from state to state, ranging from 35 percent to 6 percent, while dental assistant vacancy rates varied from 12 percent to 4 percent. Dentist Medicaid participation and volume differed widely across the states. The majority of dentists in the four states were satisfied with their professional life, but the percentage who felt they were too busy or not busy enough varied widely among the states.
• Rural Research Focus: Rural Physician Shortages
  Author(s): George E. Wright, C. Holly A. Andrilla, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Date: 05 / 2002
  Discusses a model for understanding how many physicians a rural community can support, based on research at the WWAMI Rural Health Research Center.
• Shortages of Medical Personnel At Community Health Centers: Implications for Planned Expansion
  Author(s): Roger A. Rosenblatt; C. Holly A. Andrilla; Thomas Curtin; L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Federally Qualified Health Centers (FQHCs), Physicians, Workforce
  Citation: JAMA, 295(9), 1042-1049
  Date: 2006
  To examine the status of workforce shortages that may limit Community Health Center (CHC) expansion, the authors surveyed all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia. Analysis of the results showed that 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.
• State of the Health Workforce in Rural America: Profiles and Comparisons
  Author(s): Eric H. Larson, Karin E. Johnson, Thomas E. Norris, Denis M. Lishner, Roger A. Rosenblatt, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topic: Workforce
  Date: 08 / 2003
  Overview of rural health care workforce issues. National and state-by-state data on the health care workforce, with rural-urban comparisons and interstate comparisons. Also includes data on rural health care facilities. To request a copy, call (206) 685-0402 or email: rowe@u.washington.edu
• Trends in Professional Advice to Lose Weight Among Obese Adults, 1994-2000
  Author(s): J. Elizabeth Jackson, Mark P. Doescher, Barry G. Saver, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health promotion and disease prevention, Obesity
  Citation: Journal of General Internal Medicine, 20(9), 814-8
  Date: 2005
  The authors studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults, and found that disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. They concluded that 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
• Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
  Author(s): Kevin Grumbach, L. Gary Hart, Elizabeth Mertz, Janet Coffman, and Lorella Palazzo
  Research center: WWAMI Rural Health Research Center
  Topics: Mid-level practitioners, Physicians
  Citation: Annals of Family Medicine, 1(2), 97-104
  Date: 07 / 2003
  Compares the geographic distribution and patient populations of physician and nonphysician primary care clinicians. Includes the proportion of clinicians within each discipline practicing in rural areas, Health Professional Shortage Areas (HPSAs), and areas with vulnerable populations.
• WWAMI Physician Workforce 2005
  Author(s): Frederick M. Chen, Meredith A. Fordyce, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Physicians, Workforce
  Report Number: Working Paper No. 98
  Date: 05 / 2005
  Data on physician supply, demand, and need in the WWAMI region have not been routinely collected or reported. This report responds to a request by the University of Washington School of Medicine (UWSOM) Primary Care Steering Committee to examine the current supply and distribution of physicians in the WWAMI region. These data can help inform and guide the UWSOM in the production of physicians for the WWAMI region. The analysis utilizes the 2005 AMA Masterfile to determine the population-based supply of physicians at the state and county level, analyzed by the discipline of physician, and whether they had graduated from, or trained at the University of Washington, which is the only medical school for the five-state WWAMI region. The emphasis on primary care is important as over one-third of the WWAMI population lives in rural areas and tends to be medically underserved, relying on primary care physicians for the majority of their medical needs.
• Wyoming Physicians Are Significant Providers of Safety Net Care
  Author(s): Sharon A. Dobie, Amy Hagopian, Beth A. Kirlin, L. Gary Hart
  Research center: WWAMI Rural Health Research Center
  Topics: Health services, Physicians, Workforce
  Citation: Journal of the American Board of Family Practice, 18(6), 470-477
  Date: 11 / 2006
  Describes the contributions of family and general practice physicians from Wyoming to the health care safety net.