American Medical Association Physician Masterfile Research Articles

Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists

Study ObjectiveMany adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown. Design and SettingNational cross-sectional study. ParticipantsPediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418). InterventionsSubspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices. Main Outcome MeasuresHPV vaccination recommendation. ResultsOver half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary–subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination. ConclusionThis study revealed that many subspecialists fail to recommend HPV vaccination to adolescents with CMCs and highlights potential targets for future interventions.

The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer.

Background:Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB.Objective:To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care.Data Sources/Study Design:Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB.Results:Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12–2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28–2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95–1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82–1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics.Conclusions:Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.

Physician assistant specialty choice: Distribution, salaries, and comparison with physicians.

To describe trends in physician assistant (PA) specialty distribution, compare these trends with physicians, and quantify the relationship of PA specialty prevalence with both PA and physician salary. PA specialty and salary data were obtained from the 2013 American Academy of PAs' Annual Survey; physician specialty and salary data from the American Medical Association Physician Masterfile and the Medical Group Management Association. Analyses included descriptive statistics and linear regression. The proportion of PAs working in primary care decreased from 50% in 1997 to 30% in 2013. Substantial growth in PA proportions occurred in surgical and medical subspecialties. Regression models showed a higher prevalence of PAs in specialties with higher PA salary, higher physician salary, and higher physician-to-PA salary ratio (P<0.05). PAs are moving toward subspecialty practice. Our study suggests that demand for PAs may be an important factor driving the trend toward specialization.

Refractory Hypoxemia and Use of Rescue Strategies. A U.S. National Survey of Adult Intensivists.

The management of severe and refractory hypoxemia in critically ill adult patients is practice based. Variability across individual practitioners and institutions is not well documented. To conduct a nationwide survey of critical care physicians in the United States regarding accepted definitions and management strategies for severe and refractory hypoxemia. A web-based survey was distributed to a stratified random sample of adult intensivists listed in the American Medical Association Physician Masterfile. The survey was generated by using a mixed-methods approach. In the survey, 4,865 e-mails were sent and 791 (16.3%) were opened. Among those who opened the e-mail message, 50% (n = 396) responded, representing 8.1% of total surveys sent. Seventy-two percent stated that their institutions lacked a protocol for identification and management of severe or refractory hypoxemia in the setting of acute respiratory failure. While the majority of respondents used low-Vt ventilation (81%), high positive end-expiratory pressure (86%), recruitment maneuvers (89%), and either bolus or infusion neuromuscular blockade (94%), there was marked variability in the use of specific rescue strategies as tier 1 or 2 interventions: prone position (27.8% vs. 47.8%, respectively), extracorporeal membrane oxygenation (2.3% vs. 51.2%, respectively), airway pressure release ventilation (49% vs. 34.5%, respectively), inhaled vasodilators (30.1% vs. 40%, respectively), and high-frequency oscillatory ventilation (7.8% vs. 40%, respectively). The variability was partly explained by providers' expertise with particular rescue strategies (77.7%), advance directives (70.1%), the training of allied health staff (62.3%), and institutional availability (53.8%). U.S. adult critical care physicians predominantly employ lung-protective ventilation for severe hypoxemia. A wide variation in other rescue strategies is noted, which is partly explained by user expertise and availability. Less than 30% institutions have formal protocols for management of refractory hypoxemia.

Perceptions and Utilization of Lung Cancer Screening Among Primary Care Physicians

IntroductionLung cancer screening (LCS) with low-dose computed tomography (LDCT) is effective at reducing lung cancer mortality in high-risk current and former smokers. Despite the fact that screening is recommended by the U.S. Preventative Services Task Force (USPSTF), few eligible patients are screened. We set out to study the barriers to LCS by surveying primary care physicians (PCPs). MethodsWe surveyed a randomly selected sample of 1384 eligible PCPs between January and October 2015, using the American Medical Association Physician Masterfile, though surveys sent by mail, fax, and e-mail. The survey included questions regarding knowledge of LCS guidelines, utilization of LCS over the prior 12 months, and perceptions of barriers to LCS. Training background, years in practice, practice type, and demographics were also collected. ResultsThe survey response rate was 18%. Responders and nonresponders did not differ by practice or demographic characteristics. Of the respondents, 47% indicated that LCS was recommended by the USPSTF, 52% had referred at least one patient for LDCT, and 12% had referred at least one patient to a LCS program over the prior 12 months. Perceived barriers to LCS included uncertainty regarding ther benefit of LCS, concern regarding insurance coverage, and the harm of LCS. ConclusionsAlthough LCS is recommended by the USPSTF, LDCT is utilized in a minority of eligible patients, as reported by surveyed PCPs. Approximately half of PCPs are familiar with USPSTF recommendations for LCS and a number of physician barriers to adherence to guidelines exist. Additional study of physician- and system-based interventions to improve adherence to LCS recommendations is needed.

Health Care Segregation, Physician Recommendation, and Racial Disparities in BRCA1/2 Testing Among Women With Breast Cancer.

Racial disparities in BRCA1/2 testing have been documented, but causes of these disparities are poorly understood. The study objective was to investigate whether the distribution of black and white patients across cancer providers contributes to disparities in BRCA1/2 testing. We conducted a population-based study of women in Pennsylvania and Florida who were 18 to 64 years old and diagnosed with invasive breast cancer between 2007 and 2009, linking cancer registry data, the American Medical Association Physician Masterfile, and patient and physician surveys. The study included 3,016 women (69% white, 31% black), 808 medical oncologists, and 732 surgeons. Black women were less likely to undergo BRCA1/2 testing than white women (odds ratio [OR], 0.40; 95% CI, 0.34 to 0.48; P < .001). This difference was attenuated but not eliminated by adjustment for mutation risk, clinical factors, sociodemographic characteristics, and attitudes about testing (OR, 0.66; 95% CI, 0.53 to 0.81; P < .001). The care of black and white women was highly segregated across surgeons and oncologists (index of dissimilarity 64.1 and 61.9, respectively), but adjusting for clustering within physician or physician characteristics did not change the size of the testing disparity. Black women were less likely to report that they had received physician recommendation for BRCA1/2 testing even after adjusting for mutation risk (OR, 0.66; 95% CI, 0.54 to 0.82; P < .001). Adjusting for physician recommendation further attenuated the testing disparity (OR, 0.76; 95% CI, 0.57 to 1.02; P = .06). Although black and white patients with breast cancer tend to see different surgeons and oncologists, this distribution does not contribute to disparities in BRCA1/2 testing. Instead, residual racial differences in testing after accounting for patient and physician characteristics are largely attributable to differences in physician recommendations. Efforts to address these disparities should focus on ensuring equity in testing recommendations.

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD.

Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States. We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015. In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups. Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

Availability of Mental Health Services Prior to Health Care Reform Insurance Expansions.

This study sought to examine psychiatrists' perceptions of gaps in the availability of mental health and substance use services and their ability to spend sufficient time and provide enough visits to meet patients' clinical needs. A cross-sectional probability survey of U.S. psychiatrists was fielded during September through December 2013 by using practice-based research methods, including distribution by priority mail. Psychiatrists (N=2,800) were randomly selected from the American Medical Association Physician Masterfile, and 1,188 of the 2,615 (45%) with deliverable addresses responded. Of those, 93% (N=1,099) reported currently treating psychiatric patients, forming the sample for this study. Thirty percent or more of psychiatrists reported being unable to provide or find a source for each of the following services in the past 30 days: psychotherapy, housing, supported employment, case management or assertive community treatment, and substance use treatment. Approximately 20% reported being unable to provide or find a source for inpatient treatment, psychosocial rehabilitation, general medical care, pharmacologic treatment, and child and adolescent treatment. Approximately half (52%) of psychiatrists reported not having enough time during patient visits, affecting 28% of patients. More than one-third (37%) reported being unable to provide enough visits to meet patients' clinical needs, affecting 24% of patients. Psychiatrists reported constrained availability of a range of mental health, substance use, and general medical services. In order for the Affordable Care Act to realize the promise of increased access to care, the infrastructure for mental health and substance use treatment, workforce, and services delivery may require significant enhancement.

MP57-19 THE INFLUENCE OF BOARD CERTIFICATION ON OUTCOMES AFTER RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III1 Apr 2016MP57-19 THE INFLUENCE OF BOARD CERTIFICATION ON OUTCOMES AFTER RADICAL PROSTATECTOMY Daniel Rosen, Julian Hanske, Gally Reznor, Christopher Allard, Christian Meyer, Jairam Eswara, Steven Chang, Maxine Sun, Paul Nguyen, Adam Kibel, Quoc-Dien Trinh, and Mark Preston Daniel RosenDaniel Rosen More articles by this author , Julian HanskeJulian Hanske More articles by this author , Gally ReznorGally Reznor More articles by this author , Christopher AllardChristopher Allard More articles by this author , Christian MeyerChristian Meyer More articles by this author , Jairam EswaraJairam Eswara More articles by this author , Steven ChangSteven Chang More articles by this author , Maxine SunMaxine Sun More articles by this author , Paul NguyenPaul Nguyen More articles by this author , Adam KibelAdam Kibel More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author , and Mark PrestonMark Preston More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.673AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The effect of several surgeon characteristics on radical prostatectomy (RP) outcomes is well established; however it is unknown how board certification status influences outcomes of surgery. This study examined the effect of board certification on RP outcomes. METHODS The Surveillance, Epidemiology, and End Results (SEER) was linked to Medicare claims and the American Medical Association Physician Masterfile and examined for RPs performed between 1992 and 2009. Quality metrics examined included performance of lymphadenectomy (LND) at RP, receipt of adjuvant therapy, complications, readmissions and emergency department (ED) visits within 30/90 days, urinary and sexual toxicities within 2 years. RESULTS The study identified 26,704 men with complete records. Overall, 1.2% (326) and 98.8% (26,378) of patients underwent RP by non-board certified and board certified urologists, respectively. Non-board certified urologists were more often in the lowest annual surgical volume bracket (82.5% vs. 26.2%, p<0.001), and less likely to have undergone surgical training in the US (81.3% vs. 92.1%, p<0.001) relative to their board-certified peers. Patients treated by non-board certified urologists were more likely to experience complications (Odds ratio (OR)=1.43; 95% Confidence Interval (CI): 1.13-1.81), readmissions (OR=2.11; 95%CI: 1.05-4.27), and emergency department visits (OR=2.02; 95%CI: 1.31-3.10) within 90 days. Additionally, they were more likely to experience urinary toxicities (hazard ratio [HR]=1.47; 95%CI: 1.21-1.78) relative to patients treated by board certified urologists. Patients treated by non-board certified urologists were less likely to receive a LND at RP (OR=0.49; 95%CI: 0.39-0.63), and more likely to receive androgen deprivation therapy (ADT) adjuvant therapy (OR=1.41; 95%CI: 1.11-1.80). CONCLUSIONS This study confirms and quantifies the effect of board certification on the outcomes of RP for localized prostate cancer. The performance of RP by a board certified urologist is associated with lower odds of complications, readmissions, ED visits, and long-term urinary toxicities, as well as higher odds of LND and lower odds of receipt of ADT. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e760 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel Rosen More articles by this author Julian Hanske More articles by this author Gally Reznor More articles by this author Christopher Allard More articles by this author Christian Meyer More articles by this author Jairam Eswara More articles by this author Steven Chang More articles by this author Maxine Sun More articles by this author Paul Nguyen More articles by this author Adam Kibel More articles by this author Quoc-Dien Trinh More articles by this author Mark Preston More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Association Between a Sense of Calling and Physician Well-Being: A National Study of Primary Care Physicians and Psychiatrists.

This study assesses the association between calling and physician well-being, clinical commitment, and burnout. In 2009-2010, a survey was mailed to 1504 primary care physicians (PCPs) and 512 psychiatrists drawn from the American Medical Association Physician Masterfile. The primary independent variable was a single-item measure that assessed physicians' level of calling. Main outcomes were markers of physician well-being (career satisfaction and morale), clinical commitment (intentions to reduce time spent in direct patient care, leave practice in a few years), and experiences of burnout. Adjusted response rates were 63% (896/1427) for PCPs and 64% (312/487) for psychiatrists. Forty-two percent of US PCPs and psychiatrists agree strongly that their practice of medicine is a calling. Physicians with a high sense of calling were less likely than those with low to report regret in choosing medicine as a career (18 vs. 38%; odds ratio 0.3; 95% confidence interval, 0.2-0.5), wanting to go into a different clinical specialty (28 vs. 49%; OR 0.4; 95% CI, 0.2-0.6), or wanting to leave the practice of medicine in the next few years (14 vs. 25%, OR 0.4; 95% CI 0.2-0.7). Physicians with a high sense of calling were less likely to report burnout (17 vs. 31% low calling, OR 0.4; 95% CI 0.3 to 0.7). Physicians who reported that medicine was a calling may be experiencing higher levels of career satisfaction, more durable clinical commitments, and resilience from burnout. Though physicians may differ on their understanding of the concept of calling in medicine, this study highlights an important factor that should be investigated further when assessing long-term workforce retention in the fields of primary care and psychiatry.

Obstetrician–Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women

To understand obstetrician-gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span. National survey from May 2010 to January 2011 asking obstetrician-gynecologists about the need for and importance of external inspection and speculum examination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations. Mail-in survey of a national sample of obstetrician-gynecologists. Probability sample of obstetrician-gynecologists from the American Medical Association Physician Masterfile (N = 521). Proportion of obstetrician-gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important. The response rate was 62%. In a healthy 70-year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very important in the 70-year-old (63%) than in younger women (46-53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care. Obstetrician-gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.

Health Care Transition in Young Adults With Type 1 Diabetes: Perspectives of Adult Endocrinologists in the U.S.

Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. Our objective was to describe experiences, resources, and barriers reported by a national sample of adult endocrinologists receiving and caring for young adults with type 1 diabetes. We fielded an electronic survey to adult endocrinologists with a valid e-mail address identified through the American Medical Association Physician Masterfile. We received responses from 536 of 4,214 endocrinologists (response rate 13%); 418 surveys met the eligibility criteria. Respondents (57% male, 79% Caucasian) represented 47 states; 64% had been practicing >10 years and 42% worked at an academic center. Only 36% of respondents reported often/always reviewing pediatric records and 11% reported receiving summaries for transitioning young adults with type 1 diabetes, although >70% felt that these activities were important for patient care. While most respondents reported easy access to diabetes educators (94%) and dietitians (95%), fewer (42%) reported access to mental health professionals, especially in nonacademic settings. Controlling for practice setting and experience, endocrinologists without easy access to mental health professionals were more likely to report barriers to diabetes management for young adults with depression (odds ratio [OR] 5.3; 95% CI 3.4, 8.2), substance abuse (OR 3.5; 95% CI 2.2, 5.6), and eating disorders (OR 2.5; 95% CI 1.6, 3.8). Our findings underscore the need for enhanced information transfer between pediatric and adult providers and increased mental health referral access for young adults with diabetes post-transition.

Psychiatrists' Comfort Using Computers and Other Electronic Devices in Clinical Practice.

This report highlights findings from the Study of Psychiatrists' Use of Informational Resources in Clinical Practice, a cross-sectional Web- and paper-based survey that examined psychiatrists' comfort using computers and other electronic devices in clinical practice. One-thousand psychiatrists were randomly selected from the American Medical Association Physician Masterfile and asked to complete the survey between May and August, 2012. A total of 152 eligible psychiatrists completed the questionnaire (response rate 22.2%). The majority of psychiatrists reported comfort using computers for educational and personal purposes. However, 26% of psychiatrists reported not using or not being comfortable using computers for clinical functions. Psychiatrists under age 50 were more likely to report comfort using computers for all purposes than their older counterparts. Clinical tasks for which computers were reportedly used comfortably, specifically by psychiatrists younger than 50, included documenting clinical encounters, prescribing, ordering laboratory tests, accessing read-only patient information (e.g., test results), conducting internet searches for general clinical information, accessing online patient educational materials, and communicating with patients or other clinicians. Psychiatrists generally reported comfort using computers for personal and educational purposes. However, use of computers in clinical care was less common, particularly among psychiatrists 50 and older. Information and educational resources need to be available in a variety of accessible, user-friendly, computer and non-computer-based formats, to support use across all ages. Moreover, ongoing training and technical assistance with use of electronic and mobile device technologies in clinical practice is needed. Research on barriers to clinical use of computers is warranted.

Medical Schools' Industry Interaction Policies Not Associated With Trainees' Self-Reported Behavior as Residents: Results of a National Survey.

Medical students attending schools with policies limiting industry/student interactions report fewer relationships with pharmaceutical representatives. To investigate whether associations between students' medical school policies and their more limited industry interaction behaviors persist into residency. We randomly sampled 1800 third-year residents who graduated from 120 allopathic US-based medical schools, using the American Medical Association Physician Masterfile. We surveyed them in 2011 to determine self-reported behavior and preferences for brand-name prescriptions, and we calculated the strength of their medical schools' industry interaction policies using the 2008 American Medical Student Association and Institute on Medicine as a Profession databases. We used logistic regression to estimate the association between strength of school policies and residents' behaviors with adjustments for class size, postresidency career plan, and concern about medical school debt. We achieved a 44% survey response rate (n = 739). Residents who graduated from schools with restrictive policies were no more or less likely to accept industry gifts or industry-sponsored meals, speak with marketing representative about drug products, attend industry-sponsored lectures, or prefer brand-name medications than residents who graduated from schools with less restrictive policies. Residents who correctly answered evidence-based prescription questions were about 30% less likely to have attended industry-sponsored lectures (OR = 0.72, 95% CI 0.56-0.98). Any effect that medical school industry interaction policies had on insulating students from pharmaceutical marketing did not persist in the behavior of residents in our sample. This suggests that residency training environments are important in influencing behavior.

Primary Care Providers' Initial Evaluation of Children with Global Developmental Delay: A Clinical Vignette Study

To examine the decisions of pediatric primary care physicians about their diagnostic evaluation for a child with suspected global developmental delay (GDD). A survey was mailed to a sample of pediatricians (n = 600) and family physicians (n = 600) randomly selected from the American Medical Association Physician Masterfile. The survey contained a clinical vignette describing a 9-month-old nondysmorphic boy with GDD. Participants were asked their initial evaluation steps (test, refer, or both test and refer) and what types of referral and/or testing they would pursue. We examined bivariate associations between physician/clinical practice characteristics and participants' evaluation decision. More pediatricians than family physicians completed the survey (response rates: 55% vs 38%). Almost three-quarters of the respondents (74%) reported that their first step in a diagnostic evaluation would be to refer the child without testing, 22% would test only, and 4% would both test and refer. As their initial step, most physicians referred to a developmental pediatrician (58%), and only 5% would refer to a geneticist. The most commonly ordered test was general biochemical testing (64%). The most commonly ordered genetic test was a karyotype (39%). When evaluating a child with GDD, few primary care physicians would order genetic testing or refer to a genetics specialist as a first evaluation step. Future studies should examine both barriers to and utilization of a genetic evaluation for children with GDD.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care.

Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services. Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data. Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals. Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Understanding the Clustering Patterns in Physician Distribution Through Affinity Propagation.

The spatial distribution of physicians has a significant impact in public health research. It is critical to clarify whether the addresses provided by the physicians are the home addresses or the practice addresses, since the practice address is the key to understand relevant issues of maldistribution, accessibility and disparity. Through a pilot study as partial effort of the research project "Reducing Physician Distribution Uncertainty in Spatial Accessibility Research" sponsored by the National Institutes of Health (NIH award number 1R21CA182874-01), appropriate solutions were developed to differentiate the home addresses from practice addresses. This paper introduces how to understand the clustering patterns in physician distribution through Affinity Propagation, a relatively new clustering algorithm, to derive the potential extent of the practice locations for those physicians who provided home addresses. The physician data is derived from the 2014 American Medical Association (AMA) Physician Masterfile, while two counties (Fulton and DeKalb) in the metropolitan area of Atlanta, Georgia were selected as the study area. Both Euclidian distance and driving distance were applied in the AP algorithm, while gravity models based AP calculation were applied in comparison to the clustering of individual physicians. By justifying preference and similarity parameters in the AP calculation, hierarchical clustering patterns can be derived and perceived. Future research challenges in AP clustering are identified, while this pilot study can be extended with broader impact in public health research.

Variation in prostate cancer care.

The use of many medical and surgical therapies varies widely between clinicians and geographic regions. Perhaps nowhere is this more evident than in the treatment of men with early-stage prostate cancer. For this group of patients, there is substantial variation not only in the use of any local therapy (vs observation), but also in the use of specific treatmentmodalities. The former concern is particularly salientamongmenwith low-riskprostatecancer, agroupfor whom the survival benefits of local therapy are less clear, while the potential adverse effects, including urinary and sexual dysfunction, may be no less apparent. Because surgery and radiationmay represent overtreatment for some men with low-grade tumors, several clinical guidelinesnowrecommend initial observation (usually in the form of active surveillance) for patients with low-risk disease.1 In a recent article from JAMA Internal Medicine, Hoffman and colleagues2 examined the use of observation vs local therapy for men with prostate cancer, with an emphasis on understanding whether the patient or physician has a greater influence on this initial treatment choice. In a well-designed study based on data from SEER, Medicare, and the American Medical Association Physician MasterFile, the authors reported that among more than 12 000 patients diagnosed with low-risk prostate cancer from 2006 through 2009, only 20% underwent observation. Moreover, definitive treatment (mainly radiation therapy) was used by 70% and 55% of men aged 76 to 80 years and older than 80 years, respectively, patients for whom the benefits of treatment are most uncertain. JAMA INTERNALMEDICINE

Monitoring Sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: temporal and geographic patterns in the United States.

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians’ locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician “brain drain”, it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.

Association between urologist characteristics and radiation oncologist consultation for patients with locoregional prostate cancer.

Physicians managing patients with prostate cancer play a critical role in subsequent specialist consultations and initial treatment choice, especially in cases for which no consensus exists regarding optimal treatment strategy. The NCCN Guidelines for Prostate Cancer recommend radiation as a therapy option for patients with locoregional prostate cancer. The authors examined the association of urologist characteristics with the likelihood that patients would consult radiation oncologists. A retrospective cohort of 39,934 patients aged 66 years or older who were diagnosed with locoregional prostate cancer between 2004 and 2007, and the 2405 urologists who performed the patient diagnostic biopsies were constructed using the SEER-Medicare linked database and the American Medical Association Physician Masterfile. Logistic multilevel regression analysis was used to evaluate the influence of urologists' characteristics on radiation oncologist consultation within 9 months of locoregional prostate cancer diagnosis. Overall, 24,549 (61.5%) patients consulted a radiation oncologist. After adjusting for patient and urologist characteristics, patients diagnosed by urologists in noninstitutional settings (eg, physician office) were significantly more likely to consult a radiation oncologist (odds ratio [OR], 1.40; 95% CI, 1.17-1.67; P=.0002) compared with those diagnosed by urologists in institutional settings with a major medical school affiliation. In addition, patients diagnosed by urologists older than 57 years were significantly more likely to consult a radiation oncologist (OR, 1.21; 95% CI, 1.07-1.38, P=.003).