Monthly Archives: February 2015

Family Medicine Graduate Proximity to Their Site of Training: Policy Options for Improving the Distribution of Primary Care Access

Authors: Ernest Blake Fagan, MD; Claire Gibbons, PhD; Sean C. Finnegan, MS; Stephen Petterson, PhD; Lars E. Peterson, MD, PhD; Robert L. Phillips Jr, MD, MSPH; Andrew W. Bazemore, MD, MPH

BACKGROUND AND OBJECTIVES: The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location.

METHODS: Using the 2012 American Medical Association Masterfile and American Academy of Family Physicians membership file, we obtained the percentage of family physicians in direct patient care located within 5, 25, 75, and 100 miles and within the state of their family medicine residency program (FMRP). We also analyzed the effect of time on family physician distance from training site.

RESULTS: More than half of family physicians practice within 100 miles of their FMRP (55%) and within the same state (57%). State retention varies from 15% to 75%; the District of Columbia only retains 15% of family physician graduates, while Texas and California retain 75%. A higher percentage of recent graduates stay within 100 miles of their FMRP (63%), but this relationship degrades over time to about 51%.

CONCLUSIONS: The majority of practicing family physicians remained proximal to their GME training site and within state. This suggests that decentralized training may be a part of the solution to uneven distribution among primary care physicians. State and federal policy-makers should prioritize funding training in or near areas with poor access to primary care services. (Fam Med 2015;47(2):124-30.)

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Blood Pressure Lowering in Type 2 Diabetes: A Systematic Review and Meta-analysis

Connor A. Emdin, HBSc1; Kazem Rahimi, DM, MSc1; Bruce Neal, PhD2; Thomas Callender, MBChB1; Vlado Perkovic, PhD2; Anushka Patel, PhD2

Importance  Lowering blood pressure (BP) is widely used to reduce vascular risk in individuals with diabetes.

Objective  To determine the associations between BP–lowering treatment and vascular disease in type 2 diabetes.

Data Sources and Study Selection  We searched MEDLINE for large-scale randomized controlled trials of BP–lowering treatment including patients with diabetes, published between January 1966 and October 2014.

Data Extraction and Synthesis  Two reviewers independently extracted study characteristics and vascular outcome data. Estimates were stratified by baseline BP and achieved BP, and pooled using fixed-effects meta-analysis.

Main Outcomes and Measures  All-cause mortality, cardiovascular events, coronary heart disease events, stroke, heart failure, retinopathy, new or worsening albuminuria, and renal failure.

Results  Forty trials judged to be of low risk of bias (100 354 participants) were included. Each 10–mm Hg lower systolic BP was associated with a significantly lower risk of mortality (relative risk [RR], 0.87; 95% CI, 0.78-0.96); absolute risk reduction (ARR) in events per 1000 patient-years (3.16; 95% CI, 0.90-5.22), cardiovascular events (RR, 0.89 [95% CI, 0.83-0.95]; ARR, 3.90 [95% CI, 1.57-6.06]), coronary heart disease (RR, 0.88 [95% CI, 0.80-0.98]; ARR, 1.81 [95% CI, 0.35-3.11]), stroke (RR, 0.73 [95% CI, 0.64-0.83]; ARR, 4.06 [95% CI, 2.53-5.40]), albuminuria (RR, 0.83 [95% CI, 0.79-0.87]; ARR, 9.33 [95% CI, 7.13-11.37]), and retinopathy (RR, 0.87 [95% CI, 0.76-0.99]; ARR, 2.23 [95% CI, 0.15-4.04]). When trials were stratified by mean baseline systolic BP at greater than or less than 140 mm Hg, RRs for outcomes other than stroke, retinopathy, and renal failure were lower in studies with greater baseline systolic BP (P interaction <0.1). The associations between BP-lowering treatments and outcomes were not significantly different, irrespective of drug class, except for stroke and heart failure. Estimates were similar when all trials, regardless of risk of bias, were included.

Conclusions and Relevance  Among patients with type 2 diabetes, BP lowering was associated with improved mortality and other clinical outcomes with lower RRs observed among those with baseline BP of 140 mm Hg and greater. These findings support the use of medications for BP lowering in these patients.