Identifying Value-Driven Approaches to Strengthening the VA Physician Workforce

背景：初级保健医生(PCP)短缺是面临的一个重大且日益严重的问题 美国的医疗体系。预计到2025年，美国将出现高达53,000个PCP的总体短缺，部分原因是 由于人口老龄化、疾病负担不断增加和 住院医生对初级保健职业的兴趣下降。最近，退伍军人管理局的PCP短缺 由于强调改善退伍军人获得高质量和及时的机会，因此受到越来越多的关注 医疗保健。要及时获得初级保健，需要有足够多的初级保健医生队伍。然而，截至 据报道，2016年5月，退伍军人管理局一直试图填补多达500个PCP职位，约占 目前的退伍军人事务部PCP员工队伍。以前的研究没有考察过几个重要的个人、经济、工作和 与卫生系统招募和保留初级保健医生有关的系统一级因素。这些 未得到充分研究的因素包括薪酬构成、学历背景、薪酬构成要素 以患者为中心的医疗家庭模式和工作环境，代表退伍军人事务部数据提供的领域 独一无二的贡献。此外，之前没有任何研究检查过这些因素在 解释五氯联苯的招募和保留。确定与PCP相关的关键因素并确定优先顺序 就业选择将帮助退伍军人管理局和其他卫生系统战略性地招聘初级保健医生和 制定以证据为基础的战略，以留住高质量的项目控制点。 目标：本研究的目标是：1)确定个人、工作、经济和制度的优先顺序- 与选择退伍军人管理局就业和选择农村业务(即招聘)有关的水平因素 使用现有的VA数据以及为本研究收集的新的定性和调查数据，2)确定和 优先考虑与长期保留PCP相关的个人、工作、经济和系统层面的因素 在退伍军人管理局和农村退伍军人管理局诊所使用行政数据和现有调查数据。 方法：这项混合方法研究将检验退伍军人管理局的管理数据、现有的退伍军人问卷调查数据、 为该项目收集的公共卫生资源数据和新的定性和调查数据。衡量因素 与退伍军人管理局招聘和农村实践环境选择相关(目标1)，我们将进行有组织的 当前内科住院医师在培训期间暴露于VA环境和新的PCP的访谈 有一个永久的退伍军人职位。然后，我们将开发和管理一个新的调查工具，使用关键因素 在定性访谈和本研究中特别感兴趣的因素中确定。然后将使用三角测量 评估定性分析中确立的关键因素和主题是否适用于更大范围 内科住院医师和新退伍军人专科医生的人口。我们将进行描述性分析，以比较 在居民和新的初级保健医生之间的访谈和调查中确定了影响因素。多变量分析 将用于确定与考虑退伍军人就业和农村地区显著相关的因素 在内科住院医师中执业。对于目标2，我们将使用退伍军人管理局管理数据库来跟踪 退伍军人初级保健医生纵向就业状况。我们将确定分配给初级保健小组的所有初级保健医生 达到最低临床全职当量(FTE)阈值并随时受雇于退伍军人管理局的患者 2003年至2016年期间。我们将把行政数据与退伍军人事务部和公众调查数据联系起来，审查关键 利益因素。将应用生存数据分析的统计方法来评估 假设因素对季度保留概率和PCP的预期持续时间的退伍军人就业。 平行分析将评估五氯苯酚在农村退伍军人设施中的滞留情况。二次分析将检查 使用扩展的两部分模型的临床FTE的纵向轮廓。在这两个目标中，我们将应用计量经济学 包括Shapley值分解在内的方法来划分五氯酚招募和保留的变化 用关键的解释因素和因素组合来解释。

Background: Primary care physician (PCP) shortages are a significant and growing problem confronting the US healthcare system. An overall shortage of up to 53,000 PCPs is projected in the US by 2025, due in part to increased demand for primary care services because of an aging population, growing disease burden and a declining interest in primary care careers among medical residents. A shortage of PCPs in VA has recently come under increased focus due to the emphasis on improving Veterans’ access to high quality and timely healthcare. Providing timely access to primary care requires a sufficiently large PCP workforce. However, as of May 2016, VA was reported to have been trying to fill up to 500 PCP positions, reflecting roughly 12% of the current VA PCP workforce. Prior research has not examined several important individual, economic, job and system-level factors associated with the recruitment and retention of PCPs by health systems. These understudied factors include components of pay and compensation, academic affiliation, elements of the patient-centered medical home model and workplace climate, which represent areas where VA data offer unique contributions. In addition, no prior research has examined the relative importance of factors in explaining PCP recruitment and retention. Identifying and prioritizing key factors associated with PCPs’ employment choices will help VA and other health systems with the strategic recruitment of PCPs and the development of evidence-based strategies to retain high quality PCPs. Objectives: The objectives of this study are to: 1) identify and prioritize individual, job, economic and system- level factors associated with the choice of VA for employment and selection of rural practice (i.e. recruitment) using existing VA data as well as new qualitative and survey data collected for this study and 2) identify and prioritize individual, job, economic and system-level factors associated with long-run retention of PCPs within VA and in rural VA clinics using administrative data and existing survey data. Methods: This mixed methods study will examine VA administrative data, existing VA employee survey data, public health resource data and new qualitative and survey data collected for this project. To measure factors associated with VA recruitment and choice of rural practice setting (Aim 1), we will conduct structured interviews with current internal medicine residents exposed to VA settings during their training and new PCPs with a permanent VA position. We will then develop and administer a new survey instrument using key factors identified in qualitative interviews and factors of particular interest in this study. Triangulation will then be used to assess whether key factors and themes established in qualitative analyses generalize to the larger population of internal medicine residents and new VA PCPs. We will perform descriptive analyses to compare influential factors identified in interviews and surveys between residents and new PCPs. Multivariable analyses will be used to identify factors that are significantly associated with consideration of VA employment and rural practice among internal medicine residents. For Aim 2, we will use VA administrative databases to track the employment status of VA PCPs longitudinally. We will identify all PCPs assigned to a panel of primary care patients who met a minimum clinical full-time equivalent (FTE) threshold and were employed by VA at any time during the period 2003-2016. We will link administrative data with VA and public survey data to examine key factors of interest. Statistical methods for survival data analysis will be applied to assess the influence of hypothesized factors on quarterly retention probabilities and PCPs’ expected duration of VA employment. Parallel analyses will assess PCP retention in rural VA facilities. Secondary analyses will examine the longitudinal profile of clinical FTE using an extended two-part model. In both aims, we will apply econometric methods including Shapley value decompositions to partition the variation in PCP recruitment and retention explained by key explanatory factors and factor combinations.