American Medical Association Physician Masterfile Research Articles

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use

ObjectivesWe estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use. MethodsWe used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training. ResultsA total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications. ConclusionsSufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.

Physicians' perspectives on percutaneous left atrial appendage occlusion for patients with atrial fibrillation

There has been an increasing uptake of transcatheter left atrial appendage occlusion (LAAO) for stroke reduction in atrial fibrillation. To investigate the perceptions and approaches among a nationally representative sample of physicians. Using the American Medical Association Physician Masterfile, we selected a random sample of 500 physicians from each of the specialties: general cardiologists, interventional cardiologists, electrophysiologists, and vascular neurologists. The participants received the survey by mail up to three times from November 9, 2021 to January 14, 2022. In addition to the questions about experiences, perceptions, and approaches, physicians were randomly assigned to 1 of the 4 versions of a patient vignette: white man, white woman, black man, and black woman, to investigate potential bias in decision-making. The top three reasons for considering LAAO were: a history of intracranial bleeding (94.3%), a history of major extracranial bleeding (91.8%), and gastrointestinal lesions (59.0%), whereas the top three reasons for withholding LAAO were: other indications for long-term oral anticoagulation (87.7%), a low bleeding risk (77.0%), and a low stroke risk (65.6%). For the reasons limiting recommendations for LAAO, 59.8% mentioned procedural risks, 42.6% mentioned "limiting efficacy data comparing LAAO to NOAC" and 32.8% mentioned "limited safety data comparing LAAO to NOAC." There was no difference in physicians' decision-making by patients' race, gender, or the concordance between patients' and physicians' race or gender. In the first U.S. national physician survey of LAAO, individual physicians' perspectives varied greatly, which provided information that will help customize future educational activities for different audiences. Although diverse practice patterns of LAAO have been documented, little is known about the reasoning or perceptions that drive these variations. Unlike prior surveys that were directed to Centers that performed LAAO, the current survey obtained insights from individual physicians, not only those who perform the procedures (interventional cardiologists and electrophysiologists) but also those who are closely involved in the decision-making and referral process (general cardiologists and vascular neurologists). The findings identify key evidence gaps and help prioritize future studies to establish a consistent and evidence-based best practice for AF stroke prevention.

The distribution of child physicians and early academic achievement.

To describe the distribution of pediatricians and family physicians (child physicians) across school districts and examine the association between physician supply and third-grade test scores. Data come from the January 2020 American Medical Association Physician Masterfile, the 2009-2013 and 2014-2018 waves of American Community Survey 5-Year Data, and the Stanford Education Data Archive (SEDA), which uses test scores from all U.S. public schools. We use covariate data provided by SEDA to describe student populations. This descriptive analysis constructs a physician-to-child-population ratio for every school district in the country and describes the child population served by the current distribution of physicians. We fit a set of multivariable regression models to estimate the associations between district test score outcomes and district physician supply. Our model includes state fixed effects to control for unobservable state-level factors, as well as a covariate vector of sociodemographic characteristics. Public data from three sources were matched by district ID. Physicians are highly unequally distributed across districts: nearly 3640 (29.6%) of 12,297 districts have no child physician, which includes 49% of rural districts. Rural children of color in particular have very little access to pediatric care, and this inequality is more extreme when looking exclusively at pediatricians. Districts that have higher child physician supplies tend to have higher academic test scores in early education, independent of community socioeconomic status and racial/ethnic composition. While the national data show this positive relationship (0.012 SD, 95% CI, 0.0103-0.0127), it is most pronounced for districts in the bottom tertile of physician supply (0.163 SD, 95% CI, 0.108-0.219). Our study demonstrates a highly unequal distribution of child physicians in the U.S., and that children with less access to physicians have lower academic performance in early education.

A Physician's Sense of Responsibility to Address Disparities: Does It Relate to Reported Behaviors About Screening for and Addressing Social Needs?

It is widely accepted that negative social determinants of health (e.g., poverty) are underlying drivers of poor health and health disparities. There is overwhelming support among physicians to screen for patient-level social needs, but only a minority of clinicians actually do so. The authors explored potential associations between physician beliefs about health disparities and behaviors to screen and address social needs among patients. The authors used 2016 data from the American Medical Association Physician Masterfile database to identify a purposeful sample of U.S. physicians (n = 1,002); data obtained in 2017 were analyzed. Chi-squared tests of proportions and binomial regression analyses were employed to investigate associations between the belief that it is a physician's responsibility to address health disparities and perceptions of physician behaviors to screen for and address social needs, accounting for physician, clinical practice, and patient characteristics. Of 188 respondents, respondents who felt that physicians have a responsibility to address health disparities were more likely than their peers (who did not feel that physicians have such a responsibility) to report that a physician on their health care team would screen for social needs that were psychosocial (e.g., safety, social support) (45.5% vs 29.6%, P = .03) and material (e.g., food, housing) (33.0% vs 13.6%, P < .0001). They were also more likely to report that a physician on their health care team would address both psychosocial needs (48.1% vs 30.9%, P = .02) and material needs (21.4% vs 9.9%, P = .04). With the exception of screening for psychosocial needs, these associations persisted in adjusted models. Engaging physicians to screen for and address social needs should couple efforts to expand infrastructure with educational efforts about professionalism and health disparities, especially underlying drivers such as structural racism and the social determinants of health.

Different Types of Patient Health Information Associated With Physician Decision-making Regarding Cancer Screening Cessation for Older Adults

Although guidelines use limited life expectancy to guide physician decision-making regarding cessation of cancer screening, many physicians recommend screening for older adults with limited life expectancies. Different ways of presenting information may influence older adults' screening decision-making; whether the same is true for physicians is unknown. To examine how different ways of presenting patient health information are associated with physician decision-making about cancer screening cessation for older adults. A national survey was mailed from April 29 to November 8, 2021, to a random sample of 1800 primary care physicians and 600 gynecologists from the American Medical Association Physician Masterfile. Primary care physicians were surveyed about breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed about breast cancer screening. Using vignettes of 2 older patients with limited life expectancies, 4 pieces of information about each patient were presented: (1) description of health conditions and functional status, (2) life expectancy, (3) equivalent physiological age, and (4) risk of dying from the specific cancer in the patient's remaining lifetime. The primary outcome was which information was perceived to be the most influential in screening cessation. The final sample included 776 participants (adjusted response rate, 52.8%; mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]). The 2 types of information that were most often chosen as the factors most influential in cancer screening cessation were description of the patient's health or functional status (36.7% of vignettes [569 of 1552]) and risk of death from cancer in the patient's remaining lifetime (34.9% of vignettes [542 of 1552]). Life expectancy was chosen as the most influential factor in 23.1% of vignettes (358 of 1552). Physiological age was the least often chosen (5.3% of vignettes [83 of 1552]) as the most influential factor. Description of patient's health or functional status was the most influential factor among primary care physicians (estimated probability, 40.2%; 95% CI, 36.2%-44.2%), whereas risk of death from cancer was the most influential factor among gynecologists (estimated probability, 43.1%; 95% CI, 34.0%-52.1%). Life expectancy was perceived as a more influential factor in the vignette with more limited life expectancy (estimated probability, 27.9%; 95% CI, 24.5%-31.3%) and for colorectal cancer (estimated probability, 33.9%; 95% CI, 27.3%-40.5%) or prostate cancer (28.0%; 95% CI, 21.7%-34.2%) screening than for breast cancer screening (estimated probability, 14.5%; 95% CI, 10.9%-18.0%). Findings from this national survey study of physicians suggest that, in addition to the patient's health and functional status, the cancer risk in the patient's remaining lifetime and life expectancy were the factors most associated with physician decision-making regarding cancer screening cessation; information on cancer risk in the patient's remaining lifetime and life expectancy is not readily available during clinical encounters. Decision support tools that present a patient's cancer risk and/or limited life expectancy may help reduce overscreening among older adults.

Abstract P4-07-09: Identifying Drivers of First-Line HR+/HER2- Metastatic Breast Cancer Treatment Choices

Abstract Background: Despite demonstrated clinical benefits of first line (1L) cyclin-dependent kinases 4/6 inhibitors (CDK4/6i) and their preferred status in the NCCN guidelines, many appropriate patients with hormone receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-) metastatic breast cancer (mBC) in the United States (US) may still receive chemotherapy or endocrine monotherapy. US oncologists may consider treatment expectations, patient clinical characteristics, and non-clinical factors (e.g., cost, anticipated adherence) when selecting 1L mBC treatment regimens. However, little is known about how prevalent these decision factors are among US oncologists. Comprehensively understanding the decision-making process in 1L treatment selection is a critical step towards ensuring equitable care for patients with HR+/HER2- mBC. Objective: To describe self-reported clinical and non-clinical factors considered by US oncologists in selection of 1L treatment for HR+/HER2- mBC. Methods: Data were collected through from an anonymous cross-sectional online survey from a convenience sample of US oncologists from August-October 2021. Eligible oncologists were board certified, in practice 2-30 years, ≥50% of time spent in direct patient care, and managed ≥5 1L patients with HR+/HER2- mBC in past 3 months. Respondents were sampled from a national research database of physicians sourced from multiple databases (e.g., American Medical Association Physician Masterfile). The survey captured self-reported demographic and practice characteristics and reported importance of the following factors in selecting 1L treatment for patients with HR+/HER2-mBC: anticipated treatment efficacy and safety, patient demographics, and clinical and non-clinical characteristics. Study variables were summarized via descriptive statistics. Correlation analyses evaluated associations between patient demographics, clinical characteristics, treatment expectations, and non-clinical characteristics and oncologists’ self-reported 1L prescribing rates of CDK4/6i, aromatase inhibitor (AI) monotherapy, and chemotherapy. Results: 250 oncologists participated; 67% from community practice and the remainder from academic institutions (Table 1). Anticipated treatment efficacy and safety/tolerability were ranked as the most important factor considered by oncologists when selecting 1L treatments. 1L CDK4/6i prescribing was most strongly correlated with patient Medicare eligibility (r, 0.54, p&amp;lt; 0.05) and postmenopausal status (r, 0.67, p&amp;lt; 0.05). 1L chemotherapy prescribing was most strongly correlated with patient premenopausal status (r, 0.42, p&amp;lt; 0.05) and perimenopausal status (r, 0.31, p&amp;lt; 0.05), and physician consideration for patient symptom burden (r, 0.31, p&amp;lt; 0.05). 1L AI monotherapy prescribing was most strongly correlated with concerns with expected patient compliance to treatment (r, 0.42, p&amp;lt; 0.05) and patient cost/logistical challenges (r, 0.41, p&amp;lt; 0.05). Conclusion: This study found a variety of patient, clinical, and non-clinical factors may underlie US oncologists’ selection of 1L treatment for HR+/HER2- mBC. Anticipated efficacy and safety/tolerability were reported as the most important factors in 1L treatment decisions. Patient demographics, clinical characteristics, and considerations for cost and compliance challenges varied in association with 1L CDK4/6i, chemotherapy, and AI monotherapy prescribing patterns among US oncologists. Table 1. Oncologist Demographic and Practice Characteristics Citation Format: Adam M. Brufsky, Martine C. Maculaitis, Lewis Kopenhafer, Patrick Olsen, Ashley S. Cha, Lillian Shahied Arruda, Wendy Heck, Samantha K. Kurosky. Identifying Drivers of First-Line HR+/HER2- Metastatic Breast Cancer Treatment Choices [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-09.

Factors Associated with Office-Based, Primary-Care Practice Among U.S. Medical Graduates: A National Cohort Study.

Purpose: Primary care (PC) career choice has been declining among U.S. medical graduates and residents since the 1990s. 1,2 By 2034, an estimated shortage of 17,800–48,000 PC physicians is expected. 2 Some medical schools have developed programs to increase students’ interest in PC specialties and practice in underserved areas. 3,4 To our knowledge, the durability of early PC-specialty preference for long-term PC practice has not been reported. Method: The Association of American Medical Colleges provided linked, deidentified data for a national cohort of 48,533 U.S. MD-granting medical school matriculants from 1998–1999 through 2000–2001. Data from the Student Records System (sex, race/ethnicity, and graduation year), Matriculating Student Questionnaire (MSQ; specialty board certification plans and attitudinal variables: importance of prestige and social responsibility in choosing a medical career), Graduation Questionnaire (GQ; total debt, plans to practice in underserved areas, and student ratings [excellent vs not excellent] of PC and non-PC clerkship experiences), and American Medical Association (AMA) Physician Masterfile practice data through May 2020 were used. The outcome was office-based practice in a specialty from the AMA Physician Masterfile, categorized as follows: (1) general-PC (i.e., internal medicine, pediatrics, family practice, general practice, internal medicine/pediatrics, or internal medicine/family practice as primary specialty, with another general-PC or unspecified secondary specialty), (2) PC-subspecialty (i.e., general-PC primary and PC-subspecialty secondary specialty, or PC-subspecialty as primary specialty), and (3) non-PC specialties (i.e., non-PC primary specialty). Multivariable logistic regression models identified variables independently associated with general-PC vs each of PC-subspecialty and non-PC-specialty practice. Results: Of 46,698 graduates in 2002–2013, 30,435 (65.2%) had complete data for analysis (7,700 [25.3%] general-PC physicians, 5,327 [17.5%] PC subspecialists, and 17,408 [57.2%] non-PC specialists). Female (vs male) students, and students with plans to practice in underserved areas (vs no plans) were more likely to report general-PC (vs PC-subspecialty) practice. Underrepresented racial/ethnic minorities in medicine (URiM), Asian/Pacific Islander (Asian/PI) students (each vs White), and students planning to pursue non-PC specialties or no board certification (each vs PC board certification plans) on the MSQ were each less likely to report general-PC (vs PC-subspecialty) practice. In the second model, female students and students reporting plans to practice in underserved areas (vs no plans), endorsing higher importance of social responsibility, or rating only PC clerkships excellent (vs rating both PC and non-PC clerkships excellent) were each more likely to report general-PC (vs non-PC-specialty) practice. URiM, Asian/PI students, students planning to pursue non-PC or no board certification, and students endorsing higher importance of prestige were each less likely to report general-PC (vs non-PC-specialty) practice. Discussion: Several factors were associated with future PC practice. The greater likelihood of women and lower likelihood of URiM graduating students to choose PC specialties on the GQ has been reported. 1 We extend this work, finding lower likelihood of URiM and A/PI physicians to be in general-PC practice. Importantly, early preference for PC specialties was positively associated with general-PC practice in both models. This may reassure medical schools considering early specialty preferences for admissions or entry into early, PC-pathway programs. Although clerkship experiences might influence students to change specialty interests, 5 to our knowledge, associations between clerkship experiences and PC practice have not been examined. We observed that students reporting excellent PC-clerkship experiences were more likely to report general-PC (vs non-PC) practice. Greater importance of social responsibility in choosing medicine also was positively associated with general-PC (vs non-PC) practice. Significance: Medical school experiences that are amenable to intervention were associated with greater odds of general-PC practice. Admitting students with early interest in PC specialties or who highly value social responsibility, fostering students’ plans to practice in underserved areas, 3,4 and improving PC-clerkship experiences may help mitigate the PC-physician shortage. Acknowledgments: The authors thank Hershel Alexander, PhD, Marie Caulfield, PhD (retired), David Matthew, PhD, and Lindsay Roskovensky, at the Association of American Medical Colleges (AAMC), for their efforts to obtain and prepare the deidentified datasets from various sources and their assistance with data coding; the National Board of Medical Examiners (NBME) Office for Research Strategy for permission to use Step 1 licensing examination data; Kristy Vanderplow at MMS, Inc., for provision of the American Medical Association (AMA) Physician Masterfile data; and Maria Pérez, MA, at Washington University School of Medicine, for data management and preparation of the data for analysis.

Race- and sex-based variation in industry research and general payments to medical oncologists in the United States.

11050 Background: Industry partnerships offer financial incentives, prestige, and can facilitate career advancement in oncology. However, not all physicians may have equal access to these opportunities. We hypothesized that physicians who are underrepresented in the medical oncology workforce based on race, ethnicity, and gender receive less industry funding. Methods: All US medical oncologists (MOs) who received ≥1 industry research payment between 2016 and 2020 according to the Open Payments database were included in this retrospective study. Information extracted from Open Payments included MO’s name, institution, research payments (i.e. funding for a research project where the physician is a Principle Investigator), and general payments (i.e. fees not associated with research, such as consulting and travel fees). Additional web searches were conducted using institutional websites, NPPES NPI registry, LinkedIn, Doximity, Scopus, and NIH RePORTER to determine each MO’s race, ethnicity, sex, academic rank, degrees, h-index, institutional NIH research funding rank, and individual receipt of NIH funding. Log-linear regression was performed to identify associations of both industry and general payment data. Results: Of 7,542 physicians meeting inclusion criteria, 69% were male, 65% White, 29% Asian, 2% Black, and 4% Hispanic, which is comparable to the American Medical Association Physician Masterfile figures for MO. The median sum research payment and general payment was $134,857 and $11,537 per physician respectively. Significantly higher mean research payments were associated with an MS (+72%; P = 0.003) or PhD degree (+30%; P = 0.009), h-index (+3%; P &lt; 0.001), top 50 institution rank by NIH funding (+44%; P &lt; 0.001), and associate professor rank (+95%; P &lt; 0.001). Significantly lower mean research payment were observed for Black physicians (-36%; P = 0.022) and those with non-academic affiliation (-47%; P &lt; 0.001). No significant association was observed between sex and research payment. Significantly higher mean general payments were associated with male sex (+46%; P &lt; 0.001), MS degree (+171%; P &lt; 0.001), h-index (+2%; P &lt; 0.001), and Asian race (+72%; P &lt; 0.001). Significantly lower mean general payments were associated with an affiliation with a non-academic practice (-31%; P = 0.012). Conclusions: Black physicians received smaller sums of industry research payments compared to White physicians. Female sex was associated with decreased general payments compared to male sex. Further exploring the underlying mechanisms determining access to industry payments may help facilitate greater equity and inclusivity in oncology.

United States 2020 Emergency Medicine Resident Workforce Analysis

To characterize the emergency medicine resident physician workforce and the residency programs training them. We identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile, analyzed demographic information, mapped both county-level population-adjusted and hospital referral region densities, and compared 2020 versus 2008 resident physician densities. We also analyzed all Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency programs from 2013 to 2020, mapped state-level population-adjusted densities, and identified temporal trends in program location and state-level program densities. All population-adjusted densities were calculated using the US Census Bureau resident population estimates. There were 6,993 emergency medicine residents in the 2020 AMA dataset with complete information. Most of them (98%) were in urban areas. Compared with 2008, per 100,000 US population, this represents disproportionate increases in urban areas (total [0.5], urban [0.5], large rural [0.2] and small rural [0.05]). We further identified 160 (2013) to 265 (2020) residency programs using the ACGME data. The new programs were 3-year training programs that were disproportionately added to states with an already higher number of programs (Florida [5 to 19], Michigan [11 to 25], New York [21 to 31], Ohio [9 to 18], Pennsylvania [12 to 21], California [14 to 22]). The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician "desert" in the rural United States, lacking both residents and residency training programs. This analysis provides essential context to the ongoing conversation about the future of the emergency physician workforce.

Medication Management of Early Pregnancy Loss: The Impact of the U.S. Food and Drug Administration Risk Evaluation and Mitigation Strategy [A289

INTRODUCTION: Early pregnancy loss (EPL) occurs in 1 million U.S. patients annually. Mifepristone pretreatment for medication management increases efficacy but requires compliance with the U.S. Food and Drug Administration Risk Evaluation and Mitigation Strategy (REMS) program. This study examined how REMS influences mifepristone use for EPL among obstetrician–gynecologists (ob-gyns) in Massachusetts. METHODS: This mixed methods study included in-depth qualitative interviews focused on EPL management analyzed under a thematic analysis framework using multiple coders and a consensus method. Qualitative data informed development of a survey fielded among all ob-gyns in Massachusetts identified through the American Medical Association Physician Masterfile. The Partners IRB deemed this study exempt. RESULTS: Nearly all interviewees (17 of 19, 89%) listed the REMS as a barrier to mifepristone use. Barriers included belief that the REMS indicated mifepristone was not available to general ob-gyns, lack of pharmacy dispensing, and concerns about signing the required prescriber agreement. The REMS sometimes gave hospital or pharmacy leadership the impression that mifepristone is dangerous, prolonging protocol development and implementation. A total of 197 physicians responded to a subsequent survey. Of those, 37% did not offer mifepristone for EPL, and 40% were not or only somewhat familiar with mifepristone's REMS program. Among those who reported on barriers to mifepristone use (n=57), the most common was uncertainty with how to comply with the REMS (53%); 73% reported that removing these regulations would help them use mifepristone for EPL. CONCLUSION: The FDA REMS program for mifepristone impedes evidence-based medication management of EPL. Removing the REMS would improve access to this best practice.

Hospital-cardiologist integration often occurs without a practice acquisition.

To describe how much of the recent increase in hospital-cardiologist integration has come from acquisitions of physician practices compared to individual employment decisions. While the role of physician practice acquisitions has received considerable attention in the news, integration may also be driven by individual physicians accepting employment at hospital-based practices. American Medical Association Physician Masterfile and Medicare data. Analysis of changes in hospital-cardiologist integration from 2011 to 2018. We measured increases in integration and changes in the number of independent and hospital-owned practices. Not applicable. In 2011, 18% of cardiologists were integrated, rising to 25% in 2016. Of this rise, 48% occurred with no acquisitions. Physicians who had completed residencies in the past 5 years (early career physicians) had higher rates of integration that also increased over time: the percentage of early career physicians joining hospital systems rose from 25% to 32%, indicating rapid growth in the number of physicians who began their careers working in hospital-based sites. A large and growing portion of hospital-cardiologist integration came from hospital employment at the individual physician level. Future policies focused on preserving competition and affordability may benefit from better understanding this form of consolidation.

Disaggregating inequalities in the career outcomes of international medical graduates in the United States.

Although research finds that international medical graduates (IMGs) fill gaps in US health care left by US medical graduates (USMGs), the extent to which IMGs' career outcomes are stratified along the lines of their country of medical education remains understudied. Using data from the 2019 American Medical Association Physician Masterfile (n=19,985), I find IMGs from developed countries chart less marginalised paths in their US careers relative to IMGs from developing countries; they are more likely to practise in more competitive and popular medical specialities; to attend prestigious residency programmes; and to practise in less disadvantaged counties that employ more USMGs relative to IMGs. These findings suggest IMGs experience divergent outcomes in the United States based on their place of medical education, with IMGs from developing countries experiencing more constraints in their careers relative to IMGs from developed countries. This understudied axis of stratification in medicine has important implications for our understanding of how nativism and racism may intersect to generate inequalities in the medical profession and in US health care more broadly.

Impact of the Rural Physician Associate Program on Workforce Outcomes.

The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School (UMMS) is a 9-month rural longitudinal integrated clerkship (LIC) for third-year medical students built on a foundation of family medicine. The purpose of this study was to examine the relationships between participation in the RPAP program and the desired workforce outcomes of practice in Minnesota, primary care specialty (particularly family medicine), and rural practice. We analyzed workforce outcomes for UMMS graduates who completed postgraduate training between 1975 and 2017, comparing RPAP participants (n=1,217) to noparticipants (n=7,928). We identified graduates through internal UMMS databases linked to the American Medical Association (AMA) Physician Masterfile and the National Provider Identifier (NPI) registry. We identified workforce outcomes of rural practice, practice in Minnesota, primary care specialty, and family medicine specialty based on practice specialty and practice location data available through the AMA and NPI data sets. Proportionally, more RPAP graduates practice in state (65.7% vs 54.4%, P&lt;.01), in primary care (69.0% vs 33.4%, P&lt;.01), in family medicine (61.1% vs 17.3%, P&lt;.01), and rurally (41.2% vs 13.9%, P&lt;.01) than non-RPAP graduates. We demonstrate a significant association between participation in RPAP and a career in family medicine, rural practice, and primary care, all outcomes that promote meeting urgent rural workforce needs.

National Study on the Contribution of Family Physicians to the US Emergency Physician Workforce in 2020.

Family physicians provide a sizable portion of emergency care in the United States. However, there is limited work characterizing this population. We completed a cross-sectional analysis of the 2020 American Medical Association Physician Masterfile that was inclusive of all clinically active physicians who designated emergency medicine as their primary or secondary specialty and had family medicine residency training and/or family medicine board certification. We used Accreditation Council for Graduate Medical Education information to determine family medicine residency training and data from the American Board of Medical Specialties to determine family medicine board certification status. We calculated physician density using US Census Bureau estimates; urban-rural assignments were based on Urban Influence Codes. We identified 4354 clinically active emergency physicians (9% of the overall emergency physician workforce). Of these, a majority were male (88%) and completed their training at least 20 years ago (84%), and a majority (59%) reported emergency medicine as their primary specialty. There is notable variation in physician density per 100,000 US population, and these densities declined compared with prior estimates from 2008. We find that family physicians represent a sizable portion of the overall emergency physician workforce despite decreases in physician densities across the United States.

The AMA Graduate Profile: Tracking Medical School Graduates Into Practice.

Purpose: Medical schools aim to train competent physicians that meet the health care needs of society. Yet beyond the results of the residency match, medical schools often do not know what kind of workforce they are creating or how their graduates perform in practice. 1 Here, we describe the creation of a personalized Graduate Profile for 32 medical schools in the American Medical Association (AMA) Accelerating Change in Medical Education grant consortium. The Graduate Profile addressed 3 core questions: (1) Workforce: Where do graduates practice and to which communities do they contribute?, (2) Clinical Exposure: What prescriptions are graduates ordering for various patient types?, and (3) Quality of Care: What are graduates’ standardized quality measures? Approach: The Graduate Profile links the AMA Physician Masterfile—a nationwide database of physicians in training and practice—to multiple public data sources spanning undergraduate medical education, graduate medical education (GME), and post-GME practice using individuals’ unique national provider identification numbers. Medical students graduating from 32 institutions between 1981 and 2012 were included (n = 120,426 graduates). Graduates’ demographics, self-designated practice specialty, practice location, and practice setting in the year 2019 were tabulated. Specialties were coded as primary care or not primary care. Practice locations were geocoded to identify practice in underserved or rural areas. Additionally, Centers for Medicare and Medicaid Services (CMS) utilization data and Merit-based Incentive Payment System (MIPS) standardized quality scores from the year 2017—representing over 140 million Medicare beneficiary interactions—were tabulated. Outcomes: Graduate Profiles were delivered to 32 medical schools in November 2020. A webinar and 2 office hours were held to support rollout of the profiles. The profiles compared each institution’s graduates from 1981 to 2012 with an average across all medical schools in a series of tables and figures. Trends in graduate gender distribution, in-state retention, practice specialty, primary care practice, office-based practice, and underserved practice were visualized and benchmarked against all 32 medical schools. For example, practice in primary care specialties peaked in the late 1990s and has since declined. Practice in medically underserved communities remained largely constant across 3 decades of graduate cohorts, suggesting that programmatic and policy efforts have not dramatically increased underserved practice. Average MIPS scores were delineated by specialty and over time. Overall, more recent graduates were associated with higher MIPS scores. Finally, graduates’ most prescribed medications to Medicare beneficiaries were tabulated. Across these 32 medical schools, the most prescribed medications were hydrocodone–acetaminophen, lisinopril, atorvastatin, omeprazole, and levothyroxine; as expected, substantial prescribing differences were observed by specialty. Each institution’s personalized profile differed, with substantial interinstitutional differences in most assessed areas. Discussion: Harnessing the AMA Physician Masterfile and multiple open data sources, this project provided medical schools with detailed profiles of their graduates—some of whom had been in practice for nearly 40 years. The project relied on data science and informatics approaches, using a centralized process that had “economy of scale.” Early feedback from medical schools indicates that the profiles are hypothesis generating and may highlight alignment (or misalignment) with their stated educational mission. We envision a future state where the constituent institutions generate questions to be answered via the Graduate Profile, which then drives medical education innovation at the medical school level. 2 Significance: The AMA Graduate Profile uses informatics approaches to link multiple data sources for 3 decades of graduates, providing medical schools a tool to understand if their graduates’ practice patterns align with their stated mission and workforce needs. The Graduate Profile is unique as it incorporates actual practice specialties, practice locations, prescribing behaviors, and standardized quality scores of over 120,000 graduates—a proof of concept for future work exploring additional domains of graduates in practice.

Rural Adolescent Immunization: Delivery Practices and Barriers to Uptake.

Rural adolescent vaccination rates lag behind urban. We sought to assess rural-urban differences in barriers to adolescent vaccination, perceived parental vaccine attitudes, and immunization delivery practices among public health nursing (PHN), pediatric (Peds), and family medicine (FM) clinicians. Internet and mail survey of Colorado PHN, Peds, and FM clinicians from June-August 2019. Study population was recruited from local health plans and the American Medical Association Physician Masterfile. Rural and urban responses were compared using Cochran Armitage trend, Fisher's exact, and chi-square tests. Response rate was 38% (163/433; 91 rural, 72 urban). Rural respondents were less likely than urban to agree most patients have insurance that covers vaccination (86% vs 97%; P = .02). Rural respondents were less likely than urban to indicate most parents in their practice would agree with statements about vaccine benefits (P = .02) and trust in medical providers (P = .05). Rural respondents were more likely than urban to report adolescents were somewhat/very likely to receive vaccines at public health departments (65% vs 28%; P < .0001) and less likely to report adolescents were somewhat/very likely to receive vaccines at pharmacies (26% vs 45%; P = .02). Fewer providers strongly recommended HPV vaccine (81% for females, 80% for males 11 to 12 years) than other adolescent immunizations (Tdap: 97%, MenACWY at 11 to 12 years: 87%; influenza at 11 to 17 years: 87%; each P < .005, rural-urban responses did not differ). Rural barriers to adolescent vaccination include logistic issues and parental vaccine attitudes. Efforts to improve rural adolescent vaccination should include public health departments and address vaccine confidence and access barriers.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study

The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction. We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients. Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction. Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia. Prognostic I.

Does experience matter? The relationship between nephrologist characteristics and end stage kidney disease patient outcomes.

Nephrology offers the unique opportunity to directly link patients to providers, allowing the study of patient outcomes at the provider level. The purpose of this analysis was to determine whether nephrologist experience, defined as years in nephrology practice, was associated with clinical outcomes. Physician data contained within the American Medical Association (AMA) Physician Masterfile was combined with patient and Medicare claims data from the United States Renal Data System (USRDS) for the calendar year 2012, with follow up extending through June 30, 2014. Associations with important healthcare outcomes including mortality in patients receiving maintenance renal replacement therapy (RRT), waitlisting for kidney transplantation, and receipt of a kidney transplant were determined with broad adjustment for both patient and provider level variables, with attention on tertile of provider time in practice. We identified 256,324 patients on maintenance RRT cared for by 6193 nephrologists. Nephrologists with the least experience were more likely to be female, reside in a region with ≥1,000,000 people, have a Doctor of Osteopathic Medicine degree, and have a listed maintenance of certification status as "yes." Overall, 30.2% of the cohort died at a mean follow up of 1.99 years. Compared to those with the 0-10 years of experience, receipt of care from nephrologists with more experience was associated with lower mortality (AHR 0.97 CI 0.94-0.99 for nephrologists with 11-20 years) and increased listing for kidney transplantation (AHR 1.10; CI 1.01-1.21 for nephrologists with >21 years experience). Experience level did not result in a difference in kidney transplantation rates. Receipt of maintenance RRT from nephrologists with greater experience was associated with decreased mortality and increased listing for kidney transplantation, an effect that remained significant after multiple adjustments for important patient and nephrologist variables.

Self-Valuation Challenges in the Culture and Practice of Medicine and Physician Well-being

ObjectiveTo compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout. Patients and MethodsA random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items. ResultsPhysicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) “often” or “always” felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) “often” or “always” put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99). ConclusionSelf-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels.