WWAMI Rural Health Research Center


Listed by publication date. You can also view these publications alphabetically.

For a complete list of publications from the Center, which may include older publications and publications funded by other sources, please see the Center's website.


  • Conrad 30 Waivers for Physicians on J-1 Visas: State Policies, Practices, and Perspectives
    Date: 03/2016

    States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study, funded by HRSA’s Federal Office of Rural Health Policy, collected quantitative and qualitative information from states to assess how state policies and practices shape IMG recruitment and practice in underserved areas through Conrad 30 J-1 visa waiver programs. The first report provides quantitative data on trends in waiver usage. The second report describes findings from interviews with Conrad 30 program personnel in 32 states and includes information on J-1 waiver physician retention for states with available data.

  • How Could Nurse Practitioners and Physician Assistants Be Deployed to Provide Rural Primary Care?
    Date: 03/2016

    New (2014) rural enrollees in the insurance plans on federal and state exchanges are expected to generate about 1.39 million primary care visits per year. At a national level, it would require 345 full-time equivalent physicians to provide those visits. This study examines how different mixes of physicians, PAs and NPs might meet the increase.

  • Outcomes of Rural-Centric Residency Training to Prepare Family Medicine Physicians for Rural Practice
    Date: 03/2016

    Little is known about how well various types of rural-centric family medicine residency training programs produce physicians for rural practice. This study examined program content and training locations as well as rural and urban practice outcomes for graduates of rural-centric family medicine residency training programs. Though numerous family medicine residencies seek to produce rural physicians, most programs required fewer than eight weeks of rural training. Among those with eight or more weeks of rural training, no single program characteristic or model offered sustained advantages over any other type in producing high yields to rural practice.

  • Access to Rural Home Health Services: Views from the Field
    Date: 02/2016

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

  • Which Physician Assistant Training Programs Produce Rural PAs? A National Study
    Date: 02/2016
    The proportion of physician assistant (PA) graduates who enter practice in rural settings has dropped over the last two decades, though PAs still continue to enter rural practice at a higher rate than primary care physicians. Between 2000 and 2012, 10% of PA training programs produced about 34% of rural PAs; those same programs produced only 14% of all the PAs graduating in the same period. This study identifies the PA training programs that produced high proportions and/or numbers of rural PAs and the program characteristics associated with that success.


  • Access to Health Information Technology Training Programs at the Community College Level
    Date: 11/2015
    Successful implementation of health information technology (HIT) in rural areas depends on the availability of a well-trained HIT workforce, and community colleges are key educational resources for producing this workforce. This study examined HIT workforce development programs in community colleges in order to increase understanding of the types of programs offered, describe the characteristics and sources of community college HIT curricula, highlight how these programs may be reaching underserved populations and students with limitations to accessing classroom-based courses, and identify barriers faced by these programs in achieving their HIT education goals. Information about the strengths and needs of the nation’s community college HIT education programs should help inform future HIT skills training programs and contribute to growing and strengthening the HIT workforce.
  • Assessing Rural-Urban Nurse Practitioner Supply and Distribution in 12 States Using Available Data Sources
    Date: 08/2015

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

  • Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States
    Date: 08/2015
    This study uses a survey of all ground-based prehospital emergency medical services (EMS) agencies in nine states (AR, FL, KS, MA, MT, NM, OR, SC, WI) to examine supply and demand for emergency response personnel, the involvement of medical directors, and the availability of medical consultation, in rural and urban agencies. Compared with urban EMS agencies, rural agencies had lower staff skill levels, higher reliance on volunteers, higher vacancy ratios, and less access to oversight and skill maintenance through regular interaction with a medical director and online medical consultation during emergency calls. Agencies in isolated small rural areas were the most distinct from other rural and urban agencies, having the most volunteers (both EMS providers and medical directors) and paid staff vacancies.
  • Recruitment of Non-U.S. Citizen Physicians to Rural and Underserved Areas through Conrad State 30 J-1 Visa Waiver Programs
    Date: 07/2015
    Conrad State 30 J-1 visa waiver programs (commonly called Conrad 30 programs) allow international medical graduates (IMGs) training in the U.S. on J-1 visas to remain in the U.S. after completing residency to provide healthcare for rural and urban medically underserved populations. This study collected information from state health department personnel, using both quantitative and qualitative methods, to characterize national trends in waivers and factors related to states’ successful recruitment of IMGs for the years 2000-01 through 2009-10. States varied greatly in the number of waivers used and in the resources devoted to operating the Conrad 30 program. Over the decade there was a shift away from rural primary care placements of IMGs toward non-rural specialist placements. States with larger populations gained an increasing share of J-1 visa waiver physicians during the decade of the 2000s. States devoting more staff to the Conrad 30 program recruited more physicians seeking waivers. Whether or not states charged applicant fees had no association with the number of waivers used.
  • Dentist Supply, Dental Care Utilization, and Oral Health Among Rural and Urban U.S. Residents
    Date: 05/2015
    Do adults in rural locations report lower dental care utilization or higher prevalence of dental disease or both compared with their urban counterparts? This analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) shows that residents of non-metropolitan counties were significantly less likely than residents of metropolitan counties to report having a dental visit or teeth cleaning in the past year and significantly more likely to report undergoing tooth extraction. These findings persisted even when controlling for demographic factors, income, insurance and health and smoking status. Policies aimed at increasing the supply of generalist dentists who will choose to work in rural areas may reduce these substantial rural/urban disparities in access to oral health care and dental outcomes.
  • Variability in General Surgical Procedures in Rural and Urban U.S. Hospital Inpatient Settings
    Date: 03/2015
    This report addresses rural/urban differences in surgical practices in commonly performed inpatient surgical procedures that are typically handled by general surgeons. National Inpatient Sample data from rural and urban hospitals in 24 states were used to examine the frequency of general surgical procedures, complications during hospitalizations and predicted resource demand. Findings indicate that rural hospitals concentrated on relatively common, low complexity procedures that can be handled by general surgeons, especially if they have received additional training in obstetrics/gynecology and orthopedics. Resource demand, length of stay, complication rates and mortality were lower for patients undergoing common procedures in rural hospitals. Rural training tracks for general surgery that provide a high case load for common general surgery, obstetrics/gynecology and orthopedics procedures may help sustain the general surgery workforce in rural areas.
  • Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder
    Date: 01/2015

    Examines the distribution of physicians authorized to treat opioid use disorder in the United States, and proposes increasing access to office-based treatment as a promising strategy to address rising rates of opioid use disorder in rural areas.


  • Health Information Technology Workforce Needs of Rural Primary Care Practices
    Date: 07/2014


    This study assessed electronic health record (EHR) and health information technology (HIT) workforce resources needed by rural primary care practices, and their workforce-related barriers to implementing and using EHRs and HIT.


    Rural primary care practices (1,772) in 13 states (34.2% response) were surveyed in 2012 using mailed and Web-based questionnaires.


    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.


    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.

  • The Contribution of Physicians, Physician Assistants, and Nurse Practitioners Toward Rural Primary Care: Findings from a 13-state Survey
    Date: 06/2014
    This study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting by physicians, physician assistants (PAs), and nurse practitioners (NPs) in rural areas. Findings suggest that although a greater reliance on PAs and NPs in rural primary care 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.
  • The Contribution of Physicians, Physician Assistants, and Nurse Practitioners Toward Rural Primary Care: Findings from a 13-State Survey
    Date: 06/2014


    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.


    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.


    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 x(2) 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.


    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).


    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.

  • Support for Rural Recruitment and Practice among U.S. Nurse Practitioner Education Programs
    Date: 05/2014
    Describes nurse practitioner (NP) education programs across the United States to identify those actively promoting NP practice in rural areas; describes their use of education methods that may promote rural practice; and identifies barriers to recruiting rural students and providing rural NP clinical training. Programs reported that relocating or commuting to campus-based programs, limited rural training opportunities, and affordability were barriers for rural students.
  • Do Rural Patients with Early-Stage Prostate Cancer Gain Access to All Treatment Choices? (Final Report)
    Date: 02/2014
    Compares rates of receipt of prostate cancer treatments and of the different treatment options between early-stage prostate cancer patients living in urban and four levels of rural counties.
  • Health Information Technology Workforce Needs of Rural Primary Care Practices
    Date: 2014
    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.




  • The Future of Family Medicine and Implications for Rural Primary Care Physician Supply (Final Report)
    Date: 08/2010
    Examines the rural physician shortage, the effect of recent trends in specialty choice on provider supply, and major trends that are changing the dynamics that shape the delivery of health care.
  • Family Medicine Residency Training in Rural Locations (Final Report)
    Date: 07/2010
    Rural physician supply has remained relatively stable over the past decade, but its future is threatened by reduced medical student interest in family medicine careers and a declining residency match rate. This 2007 survey of all U.S. family medicine residency programs found that 33 rural programs accounted for over 80% of family medicine training occurring in rural sites, although some urban programs offer rural training tracks. Expansion of rural family medicine training is limited by Medicare graduate medical education funding caps on residency slots, financial hardships facing rural hospitals, and the challenges of creating residency training programs.
  • Quality of Care for Acute Myocardial Infarction: Are the Gaps Between Rural and Urban Hospitals Closing? (Policy Brief)
    Date: 03/2010
    Many simple, evidence-based guidelines that improve acute myocardial infarction outcomes are inadequately implemented in both rural and urban hospitals. Overall, there has been improvement in acute myocardial infarction quality measures, and persistent rural-urban disparities in only a few. Particularly in small and remote small rural locations, developing strategies to increase use of beneficial discharge medications is important.


  • Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America (Policy Brief)
    Date: 09/2009
    Resources are needed to increase and sustain the number of primary care providers and reduce financial barriers to care in all rural primary care HPSAs.
  • The Aging of the Primary Care Physician Workforce: Are Rural Locations Vulnerable? (Policy Brief)
    Date: 06/2009
    Large numbers of primary care physicians are nearing retirement as fewer new U.S. medical graduates are choosing primary care careers. This policy brief describes the rural areas of the U.S. where impending retirement threatens access to primary care, and offers potential solutions to the problem.
  • The Availability of Family Medicine Residency Training in Rural Locations of the United States (Policy Brief)
    Date: 06/2009
    Family physicians constitute the largest proportion of the rural primary care physician workforce, yet declining student interest in rural family medicine may worsen rural primary care shortages.
  • The Future of Family Medicine and Implications for Rural Primary Care Physicians (Policy Brief)
    Date: 06/2009
    The crisis posed by the persistent shortage of providers in rural areas of the United States is being exacerbated by the precipitous decline in student interest in the field of family medicine. This study examines the rural physician shortage based on an analysis of a cohort of recent medical school graduates, the effect of trends in specialty selection on provider supply, and major trends impacting health care delivery.
  • The Crisis in Rural Dentistry (Policy Brief)
    Date: 04/2009
    Rural populations have fewer dentists, lower dental care utilization, and higher rates of dental caries and permanent tooth loss than urban populations. Reports from the Surgeon General and the Institute of Medicine call for more dentists in rural locations. Federal and state programs have focused on expanding rural dentist supply to increase dental access and improve oral health, but efforts may need to intensify to meet the needs of rural communities.
  • The Crisis in Rural General Surgery (Policy Brief)
    Date: 04/2009
    The dramatic decline in the number of rural general surgeons in the U.S. since the early 1980s has precipitated a crisis in rural general surgery. General surgeons are vital members of the rural health care system, performing emergency operations, underpinning the trauma care system, backing up primary care providers, reducing drive time for rural residents, and contributing to the financial viability of small hospitals.
  • The Crisis in Rural Primary Care (Policy Brief)
    Date: 04/2009
    Primary care provides initial and ongoing care for the majority of patient health care needs. Primary care providers are the backbone of rural health care, yet primary care in rural locations is in crisis. The number of students choosing primary care careers has declined precipitously. Low compensation, rising malpractice premiums, professional isolation, limited time off, and scarcity of jobs for spouses discourage the recruitment and retention of rural primary care providers.
  • Threats to the Future Supply of Rural Registered Nurses (Policy Brief)
    Date: 04/2009
    Shortages of registered nurses (RNs) in rural areas of the United States may grow even greater in coming years as the "baby boom" generation retires and as RNs commute to larger towns and urban areas for work.



  • 2005 Physician Supply and Distribution in Rural Areas of the United States (Full Report)
    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)
    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 Cancer Services for Rural Colorectal Cancer Patients (Project Summary)
    Date: 10/2007
    Brief overview of findings from a study to determine how far rural and urban colorectal cancer (CRC) patients travel to three types of specialty cancer care services: surgery, medical oncology consultation, and radiation oncology consultation.
  • Changes in the Rural Registered Nurse Workforce from 1980 to 2004 (Final Report)
    Date: 10/2007
    There are shortages of registered nurses (RNs) in most parts of the country. Rural strategies to address these shortages may differ from urban strategies, and knowledge of how the rural nurse workforce has changed over time is important for rural health policy and planning. With data from 1980-2004 National Sample Surveys of Registered Nurses, and using Rural-Urban Commuting Area definitions, this study describes changes in rural and urban RN demographics, education, and employment characteristics over time.
  • Changes in the Rural Registered Nurse Workforce from 1980 to 2004 (Project Summary)
    Date: 10/2007
    Current and projected nationwide shortages of registered nurses (RNs) threaten access to and quality of care in most parts of the country. In rural areas health care is frequently challenged by uneven distribution of health care providers, including nurses. This report shows changes in the rural registered nurse workforce from 1980 to 2004.
  • Health Center Expansion and Recruitment Survey 2004: Results by Health and Human Services Regions and Health Center Geography
    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.
  • The Washington State Nurse Anesthetist Workforce: A Case Study
    Date: 02/2007
    The purposes of this study were to describe the Washington State Certified Registered Nurse Anesthetist (CRNA) workforce and analyze selected dimensions of their clinical practice. The authors developed a 31-item CRNA Practice Questionnaire that was mailed to CRNAs licensed in Washington with an address in Washington, Oregon and Idaho. Workforce data may assist CRNAs when negotiating with employers and institutions and in resolving interprofessional conflicts and can have implications for scope of practice, policy and legislative issues.
  • A National Study of Lifetime Asthma Prevalence and Trends in Metro and Non-Metro Counties, 2000-2003 (Full Report)
    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%).
  • A National Study of Lifetime Asthma Prevalence and Trends in Metro and Non-Metro Counties, 2000-2003 (Project Summary)
    Date: 01/2007
    Brief overview of 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. A full report is also available.


  • Registered Nurse Vacancies in Federally Funded Health Centers
    Date: 12/2006
    Discusses the registered nurse (RN) vacancy rate in federally funded health centers, which varies by degree of rurality.
  • Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)
    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.
  • Wyoming Physicians Are Significant Providers of Safety Net Care
    Date: 11/2006
    Describes the contributions of family and general practice physicians from Wyoming to the health care safety net.
  • Rural Dental Practice: A Tale of Four States (Full Report)
    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 Dental Practice: A Tale of Four States (Project Summary)
    Date: 03/2006
    Overview results of a survey of rural dentists in Alabama, California, Maine, and Missouri. Provides charts and statistics on dentist demographics, dental hygienist and dental assistant vacancy rates, and dentist participation in Medicaid. A full report is also available.
  • The Changing Geography of Americans Graduating from Foreign Medical Schools
    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.
  • Do International Medical Graduates "Fill the Gap" in Rural Primary Care in the United States?
    Date: 2006
    Compares the practice locations of international medical graduates (IMGs) and U.S. medical graduates (USMGs) in primary care specialties. Report available by contacting the Center.
  • Geographic Access to Health Care for Rural Medicare Beneficiaries
    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.
  • Modeling the Mental Health Workforce in Washington State: Using State Licensing Data to Examine Provider Supply in Rural and Urban Areas
    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.
  • Prevalence and Trends in Smoking: A National Rural Study
    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
    Date: 2006
    Examines recent trends in heavy and binge drinking in urban counties and three types of rural counties.
  • Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State
    Date: 2006
    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.
  • Shortages of Medical Personnel At Community Health Centers: Implications for Planned Expansion
    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.
  • Will Rural Family Medicine Residency Training Survive?
    Date: 2006
    Reports the results of a study examining the recent performance of rural residencies in the National Resident Matching Program as an indicator of their viability.


  • Dentist Vacancies in Federally Funded Health Centers
    Date: 12/2005
    Presents results for dentists from a study of staffing needs at Federally Qualified Health Centers (FQHCs). Provides information on dentist vacancy rates by rural and urban location. Compares dentist vacancies to other health care provider vacancies at FQHCs.
  • Family Physician Vacancies in Federally Funded Health Centers
    Date: 11/2005
    Presents results for family physicians from a study of staffing needs at Federally Qualified Health Centers (FQHCs). Provides information on family physician vacancy rates by rural and urban location. Compares family physician vacancies to other physician vacancies at FQHCs.
  • Washington State Hospitals: Results of the 2005 Workforce Survey
    Date: 10/2005
    The University of Washington Center for Health Workforce Studies and the Washington State Hospital Association's Health Work Force Institute collaborated in a staffing survey of Washington's nonfederal acute care hospitals. Eighty-one percent of the 88 hospitals responded to this mailed survey. Growth in Washington's hospital sector appears to be keeping the demand for health care occupations high, even when vacancy rates for some jobs appear to be lower than in past years. This growth, and the shift away from contracting employees, needs to be considered in projections of future workforce supply and demand.
  • Pathways to Rural Practice: A Chartbook of Family Medicine Residency Training Locations and Characteristics
    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.
  • Rural Definitions for Health Policy and Research
    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.
  • WWAMI Physician Workforce 2005
    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.
  • Geographic Access to Health Care for Rural Medicare Beneficiaries
    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 the Center.
  • Heavy And Binge Drinking In Rural America: A Comparison Of Rural And Urban Counties From 1995/1997 Through 1999/2001
    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 the Center.
  • Characterizing the General Surgery Workforce in Rural America
    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.
  • Explaining Black-White Differences in Receipt of Recommended Colon Cancer Treatment
    Date: 2005
    Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care. Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.
  • The Flight of Physicians From West Africa: Views of African Physicians and Implications for Policy
    Date: 2005
    West African-trained physicians have been migrating from the sub-continent to rich countries, primarily the US and the UK, since medical education began in Nigeria and Ghana in the 1960s. In 2003, we visited six medical schools in West Africa to investigate the magnitude, causes and consequences of the migration. We conducted interviews and focus groups with faculty, administrators (deans and provosts), students and post-graduate residents in six medical schools in Ghana and Nigeria. In addition to the migration push and pull factors documented in previous literature, we learned that there is now a well-developed culture of medical migration. This culture is firmly rooted, and does not simply fail to discourage medical migration but actually encourages it. Medical school faculty are role models for the benefits of migration (and subsequent return), and they are proud of their students who successfully emigrate.
  • The Impact of U.S. Medical Students' Debt On Their Choice of Primary Care Careers: An Analysis of Data from the 2002 Medical School Graduation Questionnaire
    Date: 2005
    The authors used results from questions on the Association of American Medical Colleges' 2002 Medical School Graduation Questionnaire that focused on students' debt and career choices to examine the hypothesis that medical students' rising total educational debt is one of the factors that explains the recent decline in students' interest in family medicine and primary care. Students reported that higher levels of debt influenced their future career choices, and there was an inverse relationship between the level of total educational debt and the intention to enter primary care, with the most marked effect noted for students owing more than $150,000 at graduation. Total debt was associated with a lower likelihood of choosing a primary care career, but factors such as gender and race appeared to have more explanatory power. Female students were much more interested in primary care-and especially pediatrics-than were male students; African American students were more interested in inner-city practice than was any other identified racial or ethnic group.
  • A National Study of Obesity Prevalence and Trends by Type of Rural County
    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.
  • Trends in Professional Advice to Lose Weight Among Obese Adults, 1994-2000
    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


  • Access to Specialty Health Care for Rural American Indians: Provider Perceptions in Two States
    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 by contacting the Center.
  • Characterizing the General Surgery Workforce in Rural America
    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 by contacting the Center.
  • American Indians and Alaska Natives: How Do They Find Their Path to Medical School?
    Date: 01/2004
    Describes the findings of a study to understand the paths of American Indian and Alaska Native (AI/AN) students who successfully entered medical school.
  • Obesity Prevalence In Rural Counties: A National Study
    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 by contacting the Center.
  • An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas
    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.
  • The Migration of Physicians From Sub-Saharan Africa to the United States of America: Measures of the African Brain Drain
    Date: 2004
    The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa.
    Methods: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA.
    Results: More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools.
    Conclusions: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.
  • The Productivity of Washington State's Obstetrician-Gynecologist Workforce: Does Gender Make a Difference?
    Date: 2004
    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 <= .01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P <= .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.
  • Quality of Care for Acute Myocardial Infarction in Rural and Urban U.S. Hospitals
    Date: 2004
    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.


  • Prevalence And Trends In Smoking: A National Rural Study
    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 by contacting the Center.
  • The Contribution of Nurse Practitioners and Physician Assistants to Generalist Care in Underserved Areas of Washington State
    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.
  • State of the Health Workforce in Rural America: Profiles and Comparisons
    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
  • Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
    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.
  • Attitudes of Family Physicians in Washington State Toward Physician-Assisted Suicide
    Date: 02/2003
    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.
  • The Effects of the 1997 Balanced Budget Act on Family Practice Residency Training Programs
    Date: 2003
    Background and Objectives: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training 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 1988-1997 to 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.


  • Accounting for Graduate Medical Education Funding in Family Practice Training
    Date: 10/2002
    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 funding they 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.
  • Family Medicine Training in Rural Areas
    Date: 09/2002
    Letter 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. 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.
    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. 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.
  • Gender-Related Factors in the Recruitment of Generalist Physicians to the Rural Northwest
    Date: 09/2002
    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.
  • Perinatal and Infant Health Among Rural and Urban American Indians/Alaska Natives
    Date: 09/2002
    Provides a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health.
  • Rural-Urban Differences in the Public Health Workforce: Findings From Local Health Departments in three Rural Western States
    Date: 07/2002
    Most local health departments or districts are small and rural; two thirds of the nation's 2832 local health departments serve populations smaller than 50,000 people. Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services during a period when the health care system of which they are a part is undergoing change.

    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.

  • Rural Research Focus: Rural Physician Shortages
    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.
  • 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?
    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. Report available by contacting the Center.


  • Improving the Quality of Outpatient Care for Older Patients with Diabetes: Lessons from a Comparison of Rural and Urban Communities
    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.
  • How Many Physicians Can a Rural Community Support? A Practice Income Potential Model for Washington State
    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.
  • Gender-Related Factors in the Recruitment of Generalist Physicians to the Rural Northwest
    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. Report available by contacting the Center.
  • Local Health Districts and the Public Health Workforce: A Case Study of Wyoming and Idaho
    Date: 2001
    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.
  • National Estimates of Physician Assistant Productivity
    Date: 2001
    Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.
  • Rural Hospital Flexibility Program: The Tracking Project Reports First-year Findings
    Date: 2001
    In 1999, the Rural Hospital Flexibility Program National Tracking Team made site visits to 12 states and 24 critical access hospitals (CAHs) in order to determine the extent of program implementation in the states and the approaches that states, hospitals and communities are taking in using the Flex Program to achieve improvements in rural health care.


  • U.S. Medical Schools and the Rural Family Physician Gender Gap
    Date: 05/2000
    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 medical schools 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.
  • The Effect of the Doctor-Patient Relationship on Emergency Department Use Among the Elderly
    Date: 01/2000
    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.
  • The Distribution of Rural Female Generalist Physicians in the United States
    Date: 2000
    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.
  • Educating Generalist Physicians for Rural Practice: How Are We Doing?
    Date: 2000
    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.
  • Emergency Department Use by the Rural Elderly
    Date: 2000
    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.


  • The Production of Rural Female Generalists by U.S. Medical Schools
    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 the rural 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. Report available by contacting the Center.
  • Dimensions of Retention: A National Study of the Locational Histories of Physician Assistants
    Date: 1999
    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.
  • Metropolitan, Urban and Rural Commuting Areas: Toward a Better Depiction of the U.S. Settlement System
    Date: 1999
    Discontent with the current definition of metropolitan areas and the lack of differentiation within nonmetropolitan territory provided the incentive for the research presented here. Census tracts rather than counties were used as the building blocks for assignment of tracts, not just to metropolitan areas, but also to larger towns (10,000 to 49,999) and to smaller urban places (2,500 to 9,999). The analysis used 1990 census-defined urbanized areas and tract-to-tract commuter flows. Results include a modest shift of population from metropolitan to nonmetropolitan, as well as a significant reduction in the areal size of metropolitan areas, disaggregation of many areas, and frequent reconfiguration to a more realistic settlement form.
  • Rural and Urban Physicians: Does the Content of Their Medicare Practices Differ?
    Date: 1999
    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.


  • Availability of Anesthesia Personnel in Rural Washington and Montana
    Date: 03/1998
    Anesthesia has historically been an undersupplied specialty. Health personnel issues used to be dominated by the findings of the 1980 Graduate Medical Education National Advisory Committee study, which suggested that anesthesia would be a balanced specialty for the rest of the century. Recent studies, however, have demonstrated that there is an oversupply of all specialists, including anesthesiology. These studies take a "top down" view of health personnel through analysis of national statistics and exploration of subsets of the data by hospital size and rurality. This approach assumes that the databases of the American Hospital Association and the American Medical Association are accurate and do not take into account the presence of certified registered nurse anesthetists (CRNAs), who are the predominant providers of anesthesia care in the smallest and most remote hospitals in the United States. We compared the 1994 master file of the American Medical Association with our local knowledge of the practitioners in the rural areas of Washington state and found numerous small errors. These errors of one or two practitioners made no difference to the analysis of practitioner groups with more than approximately five people, but in the most rural communities the erroneous presence or absence of a single practitioner made a significant difference.


  • The National Health Service Corps: Rural Physician Service and Retention
    Date: 1997
    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 rural practitioners; 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.