Original Research

Urologist Workforce Variation Across the VHA

Distribution of urologists varies significantly at the facility rather than at the regional level, according to a large-scale study, but regional approaches, e-consults, and telemedicine may mitigate veteran access issues.

Fed Pract. 2015 March;32(3):18-22

Author(s):

Ted A. Skolarus, MD, MPH

Timothy P. Hofer, MSc

Jeffrey S. Montgomery, MHSA

Khaled Hafez, MD

Brent K. Hollenbeck, MS

Jeremy B. Shelton, MSHS

Anna Liza Antonio, MS

Sarah T. Hawley, PhD, MPH

Anne E. Sales

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References

1. Graham GD; Office of Specialty Care Transformation, Department of Veterans Affairs Patient Care Services. Specialty care transformation initiatives. http://www.pva.org/atf/cf/%7BCA2A0FFB-6859 -4BC1-BC96-6B57F57F0391%7D/Friday_Graham_Specialty%20Care%20Transformation%20Initiatives.pdf. Published December 2011. Accessed February 3, 2015.

2. Neuwahl S, Thompson K, Fraher E, Ricketts T. HPRI data tracks. Urology workforce trends. Bull Am Coll Surg. 2012;97(1):46-49.

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4. Odisho AY, Cooperberg MR, Fradet V, Ahmad AE, Carroll PR. Urologist density and county-level urologic cancer mortality. J Clin Oncol. 2010;28(15):2499-2504.

5. Fiscal Year 2011 VHA Physician Workforce & Support Staff Data. VHA Office of Productivity, Efficiency, & Staffing Website. https://opes.vscc.med.va.gov. Published December 2011.

6. Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. Thousand Oaks, CA: Sage Publications Inc;1999.

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9. Gee WF, Holtgrewe HL, Albertsen PC, et al. Subspecialization, recruitment and retirement trends of American urologists. J Urol. 1998;159(2): 509-511.

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The VHA is the nation’s largest integrated health care delivery system, providing comprehensive medical care to about 6 million patients annually. In addition to revolutionizing its primary care delivery through widespread implementation of patient-centered medical homes (Patient Aligned Care Teams), the VHA is also transforming its specialty care delivery through use of its specialist workforce and innovative technologies, such as telemedicine and electronic consultations (e-consults).¹

VHA specialty care is currently distributed using a hub and spoke model within larger regional networks spanning the U.S. This approach helps overcome geographic variation in specialist workforce (eg, predilection for metropolitan areas) but limits specialty care access for patients and primary care providers (PCPs) due to distance barriers.^2-4With the VHA electronic medical record (EMR) system, it is now feasible to send expertise electronically across the system (eg, e-consult). Whether this should occur at the regional VISN or national level to smooth out variation in specialist workforce depends in part on current specialist distribution within and across regions.

Hand in hand with an aging veteran population is a growing clinical demand for urologic specialty care to treat urinary incontinence, prostate enlargement, and prostate cancer. Unfortunately, over 60% of U.S. counties lack a urologist, creating troublesome workforce issues.³ For these reasons, this study analyzed existing administrative data to understand regional variations in the distribution of and demands for the VHA urologist workforce. This study tested whether workforce distribution is balanced or imbalanced across regional networks, in part to inform whether the VHA should offer electronic or other national access to its urologic specialty care.

Methods

Fiscal year (FY) 2011 Specialty Physician Workforce Annual Report data from the VHA Office of Productivity, Efficiency, and Staffing was used to characterize the distribution and concentration of urologists at 130 VHA facilities.⁵ The annual report provided a longitudinal management tool for reporting clinical productivity, efficiency, and staffing, and included benchmark data for each facility (eg, physician workforce, annual patient visits).

Demand for Urologic Specialty Care

The number of unique urology patients from the report was used as one approach to the demand for VHA urologic specialty care. This measure represented the number of unique patients evaluated in a urology clinic at least once over the FY. The number of newly diagnosed patients with prostate cancer in calendar year 2010 within each VISN was also used as a more discrete measure of regional urologic care demand. Whereas care for other common urologic conditions, such as incontinence or prostate enlargement, may or may not be referred (ie, latent demand), prostate cancer care consistently involves urologists and is more specific for caseload.

Because each VISN covered a relatively large geographic area, most with roughly equivalent numbers of facilities, there was no a priori reason to expect a difference in urologic workload and consequently urologic workforce between networks. On the other hand, within networks one might expect that urologists would be concentrated in hospitals that have more complicated patient cases, because the hospitals serve a tertiary or referral role. Yet even within a network, significant imbalances in specialist supply might require creative solutions to maintain adequate access of patients and PCPs to specialists.

Urologist Workforce

The full-time equivalent employee (FTEE) variable for urologic specialty care from the 2011 annual report was used as the primary outcome measure for urology workforce.⁵ This facility-level measure represented the clinical time urologists spent in direct patient care at each facility. It included the clinical effort of full-time as well as contract physicians and was also reported as an aggregate measure at the regional VISN level. Urologist workforce at the VISN level was the sum of all urologist FTEEs within its facilities. Adjusted rates also were provided (eg, FTEE/10,000 urology patients).

Other Workforce Factors

Also examined as covariates in the analysis were other measures related to urologist workforce. As the nation’s largest provider of graduate medical education, urology residents rotate through many VHA facilities, contributing to the workforce totals. For this reason, resident FTEE was examined as an independent variable in this study.

Understanding facility complexity (ie, case mix) was also essential for rational allocation of specialty care resources, as demand generally increases with increasing case mix. Therefore, a medical center group (MCG) case mix measure of complexity and its relationship with urologist workforce was examined. It was expected that increasing specialty care volume, resident staff, and facility complexity would be associated with increasing urologist workforce.

Statistical Analysis

Descriptive statistics were used to characterize VHA urology patients and urologist workforce within each regional VISN and its facilities. To better understand the relationship between case mix and urologist workforce, facilities were sorted according to MCG and characterized the unique urology patients, urologists, and residents at each level. Analysis of variance was used to test whether increasing MCG was associated with a higher number of urology patient caseloads. Multivariable linear regression models were then used to determine whether complexity was associated with urologist workforce after adjusting for resident and patient volume.