Current Projects

Learn more about our ongoing projects here.

Rural-urban differences within primary care scope of practice

Investigators: Ryan Kandrack, PhD(cand), Erin Fraher, PhD, Mark Holmes, PhD

There is some evidence that primary care physicians in rural areas respond to the limited local supply of specialists by offering a broader array of clinical services than their urban colleagues. These studies suggest that there is “plasticity” in the scope of services provided by physicians. Plasticity describes the dynamic and real world nature of scope of practice; physicians within the same specialty may provide different types of services depending on their demographic characteristics and training, the density of other physicians who provide overlapping services in their local area, the needs of their local patient population, and their personal preferences.  Previous studies have described primary care physicians’ plasticity between rural and urban locations but little work has been done investigating the factors that affect plasticity within primary care specialties.  The goal of this project is to investigate how the breadth and volume of primary care services varies within family medicine and general internal medicine between rural and urban areas.

Developing a GME Policy Toolkit that States Can Use to Evaluate Return on Investment for Public Funds Invested in Training

        Investigators: Erin Fraher, PhD, MPP; Tom Ricketts, PhD, MPH; Ryan Kandrack, PhD(cand)

This study will develop and refine a methodology that states can use to evaluate the return on investment for public funds spent on Graduate Medical Education (GME). Armed with data about the outcomes of GME funds invested—in terms of yield of physicians in needed specialties and geographies–states can make more informed decisions about where to target future GME funds to produce the physician workforce needed to meet population health needs and ensure value for their investment.

Descriptive analysis of the IQVIA OneKey database

Investigators: Ryan Kandrack PhD(cand); Erin Fraher, PhD

In this study, we will explore the IQVIA OneKey nursing, physician assistant, dentist, and Accountable Care Organization files in order to: document what’s in the files, how many of each profession are included (and compare to national estimates from established sources), understand exactly what each variable is/how it was derived, and identify the types of analyses the OneKey data would be well-suited for compared to other workforce datasets. Such an analysis will serve as a resource for future health workforce research.

Experience of Physician Assistants and Nurse Practitioners in Onboarding Programs

Investigators:  Perri Morgan, PA-C, PhD; Mara Sanchez, PA-C; Lorraine Anglin, PA-C, Chris Everett, PA-C, PhD

Newly graduated nurse practitioners (NPs) and physician assistants (PAs) face challenges in adapting to their first jobs, including stressful patient loads and inadequate support. Because of this, some organizations are instituting formal onboarding programs to support PAs and NPs as they transition from students to practicing clinicians. Community health centers (CHCs) increasingly rely on NPs and PAs.  Transition to practice might be especially difficult at CHCs because the patient population faces greater social and economic challenges.

This project will summarize interviews with PAs and NPs who experienced an onboarding program about their experience. Suggestions for improvement will be included.  We will:

  1. Describe the structure and content of onboarding programs that NPs and PAs experienced in CHCs and other primary care settings, and
  2. Identify strengths and areas for improvement in existing primary care onboarding programs.

Understanding Registered Nurse Turnover in the U.S.

Investigators:  Cheryl B. Jones, PhD, RN; George Knafl, PhD; Meriel McCollum, BSN, RN, PhD student

While healthcare has changed dramatically over the past decade, the turnover of registered nurses (RNs) remains a recurring challenge. Prior research indicates that nurse turnover is costly, creates an unstable workforce, and affects patient outcomes. Despite this evidence, we know very little about current RN turnover in the U.S., how it varies between different types of health care settings, or among RNs of different backgrounds.

In this study, we will use data collected through the National Sample Survey of Registered Nurses 2018 (NSSRN) to examine nurse turnover (job or employer change) behaviors as a function of sociodemographic, professional, employment, and economic factors. Study findings can be used to develop targeted strategies that will be more effective in addressing nurse turnover behaviors than a one-size-fits-all approach.

Primary care practice staffing characteristics

Investigators: Valerie Lewis PhD and Ryan Kandrack PhD(cand)

Contemporary health care policy and quality initiatives often explicitly or implicitly rely on primary care practices as a central locus for change.  Despite this, no work has systematically examined the composition of the workforce of US primary care practices; how the workforce varies across key types of practices; or how team composition has changed over time.

This project will provide more comprehensive data on staffing configurations for virtually all primary care practices in the US and will examine how these staffing patterns vary in rural versus urban areas, by practice type and ownership structure.

Trends in Physician Specialization 2004-2017

Investigators: Erin Fraher, PhD, MPP, and Andy Knapton, MSc

Congressional proposals to expand Graduate Medical Education have set a goal of funding 3,000 new PGY1 slots for five years for a total of 15,000 new residency positions.  While these proposals aim to produce the workforce needed to meet population health needs, simply increasing the number of residency positions in core specialties such as internal medicine (IM) and general surgery (GS) will produce only a fraction of the number of physicians needed.  This is because a significant proportion of these residents go on to pursue subspecialty training.

This study quantifies the number of residents in family medicine, internal medicine, psychiatry and general surgery who, between 2004 and 2017:

  1. completed training and entered practice after the minimum training length
  2. continued training in the same specialty beyond the minimum training length; and 3. went on to pursue specialty training.

The demographic, specialty, employment and geographic characteristics of physicians and residents affiliated with ACOs in the United States

Investigators: Erin Fraher PhD and Ryan Kandrack PhD(cand)

The transformation toward value is proceeding rapidly and occurring while hospitals and health systems continue to provide health services and train the future workforce. Preliminary analyses suggest that about 4,000 residents-in-training are in OneKey ACO provider roster which will allow us, for the first time we are aware of, to describe the demographic, specialty, employment and geographic characteristics of residents in ACOs. While it is unclear what being in the OneKey ACO file means in terms of the amount and content of training that is occurring in a value-based vs. fee-for-service practice environment, we will use the merged OneKey/MF data to identify the specialty, training institutions and geographic location of these resident physicians.

Geographic Access Measure for Primary Care in Rural Areas

Investigators: Mark Holmes, PhD, Paul Delamater, PhD

Urban-rural disparities have been of increasing interest in the public policy debate.  A key element in this debate, however, is the definition of rural.   Various federal agencies use distinct definitions of rurality; common definitions include the county-based Metropolitan/Micropolitan Statistical Area definition (OMB) and the Census tract (and ZIP approximation) of Rural-Urban Commuting Areas, the method primarily used by the Federal Office of Rural Health Policy (HRSA).  As the decennial Census approaches, geographers have noted potential challenges and limitations to these definitions.  For example, a decline in rural employment may increase commuting to urban job centers which might render rural areas included in metropolitan statistical areas.

In this study, we will determine how the availability of primary care physicians varies by multiple aspects of geography—e.g. the appropriate areal unit (e.g. counties vs. census tracts), population density, size, and relative proximity to urban centers—and determine the combination of factors that best explains disparities in the availability of primary care physicians. This analysis will provide insight into better targeting HRSA programs aimed at improving the health of rural communities.

Impact and responses of safety net practices in 22 states to the COVID-19 pandemic, as experienced by frontline clinicians.

Investigator: Donald Pathman, MD, MPH

We will conduct a survey of an existing cohort of 5,500 primary care, mental, dental and allied health clinicians working in FQHCs, RHCs, mental health facilities, health departments, prisons, IHS and tribal sites in 22 states to analyze how:

  1. their practices have been affected by COVID and adapted services for patients and staff through reorganization of work and administrative and engineering controls, and
  2. these clinicians are weathering the pandemic’s many work and job changes as reflected in measures of their work satisfaction, stress, burnout, moral distress, quality of life and sense of motivation and meaningfulness found in work

Professional Structures and Physician Burnout

Investigator: Tania Jenkins, PhD

An ethnographic study of 100 medical professionals in a single academic institution, including: third or fourth-year medical students; residents; fellows; early and later-career attending physicians; and hospital executives to:

  1. better understand how medical education may be interacting with healthcare system-level and institutional-level factors to produce unhealthy clinicians, thereby contributing valuable novel knowledge to both medicine and sociology, and
  2. inform upstream, structural interventions that may be used to help improve mental health in the profession

Burnout in “Essential” Workers: Understanding the Unique Experiences of Low Wage Workers in Health Systems

Investigators: Brianna Lombardi PhD, MSW; Lisa de Saxe Zerden PhD, MSW; Erica Richman PhD MSW

COVID-19 is causing significant stress amongst health care staff that will require health systems to quickly deploy strategies to address burnout or risk attrition and turnover. The COVID-19 pandemic has also highlighted how pre-existing inequities within society and our health care systems are exacerbated in times of crisis. Front-line workers in low-wage positions who more likely to be women, immigrants, and people of color and are more likely to experience physical, mental, and financial hardship related to the pandemic.  To understand the unique experiences of nursing home technicians, home health aides, medical and nursing assistants, food service, and house-keeping staff in health systems and identify needed strategies to support them during the pandemic, we will conduct in-depth qualitative interviews in four states (CA, PA, NC, and NY) with workers across three-levels of the health system (ambulatory, hospital, and long-term care settings). This project will partner with the UCSF Health Workforce Research Center for Long-Term Care to complete a total of 48 interviews.

The Impact of COVID-19 on Primary Care Practice

Investigator: Valerie Lewis, PhD

COVID19 has caused dramatic changes to primary care access and delivery that present significant issues to the primary care workforce. First, primary care practices have cancelled large swaths of in person visits while working to rapidly implement telehealth. This is coupled with dramatic declines in revenue that present organizations with difficult financial choices.  The intensity of care under COVID19 likely may be increasing burnout among clinicians. Currently, information on these changes is largely anecdotal. We propose to conduct qualitative interviews with approximately 40 primary care practices in several states, purposively sampled across key dimensions (e.g. size, rurality, ownership).

 

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