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Research ArticleOriginal Research

Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington

Kevin Grumbach, L. Gary Hart, Elizabeth Mertz, Janet Coffman and Lorella Palazzo
The Annals of Family Medicine July 2003, 1 (2) 97-104; DOI: https://doi.org/10.1370/afm.49
Kevin Grumbach
MD
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L. Gary Hart
PhD
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Elizabeth Mertz
MPA
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Janet Coffman
MPP
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Lorella Palazzo
MA
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Article Figures & Data

Tables

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    Table 1.

    Clinician Characteristics

    Percent Race, Ethnicity
    NumberPercent FemaleAfrican AmericanAsianHispanicWhiteOtherMissingAge, Years Mean (SD)
    SD = standard deviation.
    California
    Family physicians8,15320.31.813.24.745.41.933.153.1 (12.5)
    General pediatricians4,46244.92.117.73.740.02.134.549.1 (10.8)
    General internists7,98423.52.115.72.639.82.637.248.9 (11.4)
    Obstetrician-gynecologists3,69327.93.913.73.948.51.528.551.8 (11.1)
    Nurse practitioners2,50996.13.77.06.778.63.10.946.4 (8.2)
    Physician assistants83354.67.87.715.762.44.81.643.5 (8.3)
    Certified nurse-midwives41998.64.32.94.184.32.71.945.6 (7.1)
    Washington
    Family physicians2,32324.80.86.72.075.87.37.447.7 (10.3)
    General pediatricians63741.90.99.72.269.98.58.846.9 (10.2)
    General internists1,16429.70.910.12.168.66.911.344.8 (10.1)
    Obstetrician-gynecologists56933.92.18.11.974.95.47.648.4 (10.0)
    Nurse practitioners44292.10.93.21.889.63.21.447.1 (7.4)
    Physician assistants48538.82.75.84.581.64.50.845.4 (8.8)
    • View popup
    Table 2.

    Percentage of Clinicians in Each Discipline Practicing in Underserved Areas, by Type of Underserved Area

    Rural Area % (95% CI)Vulnerable Population Area % (95% CI)HPSA % (95% CI)
    CI = confidence interval, HPSA = primary care health profession shortage area.
    *Percent of state’s population residing in each type of underserved area.
    P < .001 for comparisons of percentages across disciplines in each state for each type of underserved area.
    California
    Population*13.039.028.0
    Family physicians13.2 (12.5–13.9)30.5 (29.5–31.5)24.2 (23.3–25.1)
    General pediatricians6.2 (5.5–6.9)31.0 (29.6–32.4)18.6 (17.5–19.7)
    General internists5.9 (5.4–6.4)31.5 (30.5–32.5)17.9 (17.1–18.7)
    Obstetrician-gynecologists6.3 (5.5–7.1)28.3 (26.8–29.8)16.9 (15.7–18.1)
    Nurse practitioners15.0 (13.6–16.4)34.4 (32.5–36.3)26.3 (24.6–28.0)
    Physician assistants21.7 (18.9–24.5)47.7 (44.3–51.1)35.2 (32.0–38.4)
    Certified nurse-midwives15.5 (12.0–19.0)41.1 (36.4–45.8)35.3 (30.7–39.9)
    Washington
    Population*24.040.038.6
    Family physicians23.6 (21.8–25.3)45.6 (43.5–47.6)43.5 (41.5–45.6)
    General pediatricians14.3 (11.5–17.1)43.5 (39.6–47.4)32.8 (29.1–36.5)
    General internists13.8 (11.8–15.9)54.5 (51.6–57.4)28.4 (25.8–31.1)
    Obstetrician-gynecologists13.7 (10.8–16.6)52.9 (48.7–57.1)31.6 (27.7–35.5)
    Nurse practitioners19.7 (15.9–23.5)51.8 (47.0–56.6)37.3 (32.7–42.0)
    Physician assistants27.8 (23.7–31.9)50.3 (45.8–54.7)42.1 (37.6–46.6)
    • View popup
    Table 3.

    Percentage of Clinicians in Each Discipline Practicing in Health Professions Shortage Area (HPSA), Stratified by Urban vs Rural Location

    Rural Clinicians in a HPSA % (95% CI)Urban Clinicians in a HPSA % (95% CI)
    CI = confidence interval.
    California
    Family physicians48.8 (45.8–51.8)20.5 (19.5–21.4)
    General pediatricians49.3 (43.3–55.2)16.6 (15.5–17.8)
    General internists49.2 (44.6–53.7)15.9 (15.1–16.7)
    Obstetrician-gynecologists47.0 (40.5–53.5)14.9 (13.7–16.1)
    Nurse practitioners51.1 (46.0–56.1)22.0 (20.2–23.7)
    Physician assistants60.3 (53.1–67.6)28.3 (24.8–31.8)
    Certified nurse-midwives50.0 (37.6–62.4)32.6 (27.7–37.5)
    Washington
    Family physicians79.2 (75.7–82.7)32.5 (30.3–34.7)
    General pediatricians78.0 (69.0–87.1)25.3 (21.5–29.0)
    General internists78.3 (71.6–84.9)20.4 (17.9–23.0)
    Obstetrician-gynecologists73.1 (62.6–83.6)25.1 (21.1–29.0)
    Nurse practitioners83.9 (75.6–92.2)25.9 (21.2–30.6)
    Physician assistants80.0 (72.9–87.1)27.4 (22.6–32.2)
    • View popup
    Table 4.

    Results of Regression Models: Odds Ratios of Practicing in Needy Areas, by Type of Area

    Rural Area OR (95% CI)Vulnerable Population Area OR (95% CI)HPSA OR (95% CI)
    HPSA = health professions shortage area, OR = odds ratio, CI = confidence interval.
    California
    Clinician type
        Family physician2.24 (1.93–2.60)1.12 (1.02–1.22)1.56 (1.41–1.73)
        General pediatrician1.02 (0.85–1.23)1.22 (1.10–1.34)1.16 (1.03–1.30)
        General internist0.93 (0.76–1.09)1.21 (1.11–1.33)1.09 (0.98–1.21)
        Obstetrician-gynecologist1.01.01.0
        Nurse practitioner3.17 (2.62–3.84)1.33 (1.18–1.50)1.84 (1.61–2.11)
        Physician assistant4.75 (3.80–5.92)2.18 (1.86–2.56)2.65 (2.23–3.14)
    Race, ethnicity
        Asian0.60 (0.52–0.70)1.26 (1.17–1.36)0.80 (0.73–0.88)
        African American0.30 (0.20–0.45)2.74 (2.35–3.19)1.35 (1.14–1.61)
        Latino0.77 (0.63–0.94)1.90 (1.68–2.14)1.30 (1.14–1.12)
        Other0.92 (0.69–1.22)1.17 (0.98–1.39)0.91 (0.74–1.12)
        White1.01.01.0
    Sex
        Female0.71 (0.63–0.79)1.02 (0.96–1.09)0.90 (0.84–0.97)
        Male1.01.01.0
    Age (10 years)
        Years2.29 (1.71–3.06)1.05 (0.88–1.25)1.29 (1.06–1.57)
        Years20.92 (0.89–0.95)0.99 (0.97–1.01)0.97 (0.95–0.99)
    Washington
    Clinician type
        Family physician1.85 (1.42–2.42)0.71 (0.59–0.86)1.66 (1.35–2.03)
        General pediatrician1.06 (0.75–1.49)0.66 (0.52–0.84)1.10 (0.85–1.41)
        General internist1.03 (0.76–1.39)1.15 (0.92–1.42)0.92 (0.73–1.15)
        Obstetrician-gynecologist1.01.01.0
        Nurse practitioner1.79 (1.25–2.57)1.12 (0.86–1.47)1.47 (1.11–1.95)
        Physician assistant2.35 (1.70–3.24)0.90 (0.70–1.16)1.55 (1.20–2.01)
    Race, ethnicity
        Asian0.39 (0.28–0.55)1.25 (1.02–1.54)0.77 (0.62–0.95)
        African American0.30 (0.12–0.74)2.70 (1.57–4.64)0.60 (0.35–1.05)
        Latino1.21 (0.80–1.84)2.01 (1.39–2.92)1.67 (1.16–2.39)
        Other0.61 (0.45–0.83)1.93 (1.54–2.40)0.61 (0.48–0.77)
        White1.01.01.0
    Sex
        Female0.63 (0.53–0.75)0.80 (0.70–0.92)0.71 (0.62–0.82)
        Male1.01.01.0
    Age
        Years0.72 (0.44–1.20)0.95 (0.63–1.41)0.92 (0.61–1.39)
        Years21.03 (0.98–1.08)1.01 (0.97–1.05)1.00 (0.96–1.04)
    • View popup
    Table 5.

    Practice Settings and Patient Populations of Clinicians in Urban California

    Patients in Clinicians’ Practice Who Are
    Clinicians Practicing in Community Clinics % (95% CI)Medicaid Beneficiaries Mean % (95% CI)Uninsured Mean % (95% CI)Minorities Mean % (95% CI)
    CI = confidence interval.
    P < .001 for overall differences across clinician groups for each item.
    Family physicians3.0 (0.8–5.2)9.4 (6.8–12.0)6.2 (4.6–7.9)49.3 (42.8–55.8)
    General pediatricians4.4 (1.4–7.4)19.2 (15.0–23.4)4.8 (3.1–6.5)58.1 (50.8–65.4)
    General internists3.8 (1.0–6.6)7.1 (5.0–9.3)4.2 (2.5–5.8)47.7 (40.5–55.0)
    Obstetrician-gynecologists0.01 (0.0–0.2)13.7 (9.8–17.6)4.4 (3.3–5.4)53.1 (44.5–61.7)
    Nurse practitioners20.8 18.9–22.7)25.5 (24.1–27.0)24.6 (23.0–26.1)61.5 (59.2–63.8)
    Physician assistants14.8 (11.8–17.8)31.0 (28.3–33.8)17.1 (14.9–19.2)65.4 (61.4–69.4)
    Certified nurse-midwives17.1 (12.8–21.4)43.2 (38.7–47.6)10.7 (8.2–13.2)66.3 (60.9–71.7)
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The Annals of Family Medicine: 1 (2)
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Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
Kevin Grumbach, L. Gary Hart, Elizabeth Mertz, Janet Coffman, Lorella Palazzo
The Annals of Family Medicine Jul 2003, 1 (2) 97-104; DOI: 10.1370/afm.49

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Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
Kevin Grumbach, L. Gary Hart, Elizabeth Mertz, Janet Coffman, Lorella Palazzo
The Annals of Family Medicine Jul 2003, 1 (2) 97-104; DOI: 10.1370/afm.49
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