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In 2006a€“2008, the majority of community health center (CHC) visits were made by Medicaid-insured or uninsured patients.
Physicians delivered care at 69% of CHC visits, nurse practitioners (NPs) at 21% of visits, physician assistants (PAs) at 9% of visits, and certified nurse midwives (CNMs) at 1% of visits.
NPs and CNMs saw a higher percentage of female patients aged 18a€“44 than did physicians or PAs. A higher percentage of NP and PA visits included health education and counseling services than did physician visits. For more than 40 years, community health centers (CHCs) have provided primary care and behavioral and mental health services in medically underserved communities, regardless of a patient's ability to pay (1). Comparable percentages of visits to office-based physicians with the same visit characteristics were significantly lower: 14% of visits to office-based physicians were made by Medicaid and SCHIP (10%) or uninsured (4%) patients, 45% by patients under age 45, 16% by patients of black or other minority racial groups, and 12% by Hispanic or Latino patients (data not shown). During 2006a€“2008, 69% of CHC visits were to physicians, 21% to NPs, 9% to PAs, and 1% to CNMs (Table 1).
NPs (36%) and CNMs (87%) saw a higher percentage of female patients aged 18a€“44 than did physicians (25%) or PAs (22%). Physicians were more likely than NPs to see patients aged 45 and over, both male and female. A lower percentage of patients with one or more chronic conditions visited NPs (39%) than visited physicians (52%)and PAs (58%), largely because of the younger ages of patients seen by NPs.
Physicians (72%) and PAs (72%) served as the patient's primary care provider more frequently than NPs (58%). 1 Differences between nurse midwife and physician, physician assistant, and nurse practitioner are statistically significant. 3 Differences between nurse practitioner and physician, and between nurse practitioner and physician assistant, are statistically significant. NOTES: Overall, 69% of visits were to physicians, 21% to nurse practitioners, 9% to physician assistants, and 1% to nurse midwives.
As assessed by the health care provider, 37% of CHC visits were for a new problem, 29% were for a chronic problem, 31% were for preventive care, and 3% were for other reasons. PAs treated a higher percentage of new problems (45%) than did physicians (36%) (Figure 2). Physicians (31%) and PAs (36%) had a higher percentage of visits for chronic conditions than did NPs (21%).
A higher percentage of visits to NPs (53%) and PAs (54%) included documentation of health education or counseling services in the medical record, compared with visits to physicians (42%) (Table 2). There were no differences among physicians, NPs, and PAs in the percentages of visits in which drugs or immunizations were prescribed or continued, or laboratory or other types of tests were ordered or administered.
The percentage of visits to CNMs in which laboratory and other types of tests were ordered or administered (59%) was higher than the comparable percentage for physicians (46%). The percentage of visits to CNMs in which drugs or immunizations were prescribed (58%) was lower than comparable percentages among physicians (79%), NPs (72%), and PAs (82%). 1 Differences between nurse midwife and physician, and physician assistant, are statistically significant. 4 Differences between nurse practitioner and physician, and between physician assistant and physician, are statistically significant. 5 Health education services include education about asthma, diet and nutrition, exercise, growth and development, injury prevention, stress management, tobacco use and exposure, weight reduction, and other education.
6 Nonmedication treatment includes complementary and alternative medicine, durable medical equipment, home health care, hospice care, physical therapy, radiation therapy, speech and occupational therapy, psychotherapy, other mental health counseling, excision of tissue, orthopedic care, wound care, other nonsurgical procedures, and other surgical procedures.


This report has presented 2006a€“2008 National Ambulatory Medical Care Survey (NAMCS) estimates of visits to CHC practitioners. CHCs serve predominantly low-income patients who are uninsured or who rely on public insurance (6). Health education services: Include education about asthma, diet and nutrition, exercise, growth and development, injury prevention, stress management, tobacco use and exposure, weight reduction, and related topics. Major reason for visit: The primary reason for the visit as assessed by the health care provider. Nonmedication treatment: Includes complementary and alternative medicine, durable medical equipment, home health care, hospice care, physical therapy, radiation therapy, speech and occupational therapy, psychotherapy, other mental health counseling, excision of tissue, orthopedic care, wound care, other nonsurgical procedures, and other surgical procedures. All estimates are from NAMCSa€”an annual nationally representative survey of visits to nonfederal office-based physicians in the United States, conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS).
Weights that take into account all sample stages, with adjustments for nonresponse, were used to produce average annual national estimates of physician and nonphysician clinician office visits. The weighted percentage of missing data observed in the data was as follows: patient age and sex (less than 5%), race (24%), and ethnicity (20%).
Esther Hing is with the Centers for Disease Control and Prevention's National Center for Health Statistics, Division of Health Care Statistics.
American Recovery and Reinvestment Act of 2009 (ARRA): Summary of major health care provisions [online].
All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. Leisure-time physical activity is associated with longer life expectancy, even at relatively low levels of activity and regardless of body weight, according to a study by a team of researchers led by the National Cancer Institute (NCI), part of the National Institutes of Health.
In order to determine the number of years of life gained from leisure-time physical activity in adulthood, which translates directly to an increase in life expectancy, researchers examined data on more than 650,000 adults. After accounting for other factors that could affect life expectancy, such as socioeconomic status, the researchers found that life expectancy was 3.4 years longer for people who reported they got the recommend level of physical activity. The researchers found that the association between physical activity and life expectancy was similar between men and women, and blacks gained more years of life expectancy than whites. Physical activity has been shown to help maintain a healthy body weight, maintain healthy bones, muscles and joints, promote psychological well-being, and reduce the risk of certain diseases, including some cancers. In 2001, the government launched the Federal Health Center Growth Initiative, providing funds over 5 years to increase by 60% the number of patients served in 1,200 communities.
The majority of visits to CHCs (55%) were made by patients who were poor or publicly insured [41% Medicaid or State Children's Health Insurance Program (SCHIP) and 14% uninsured] and by patients under age 45 (64%) (Figure 1). Only 3% of visits involved both a physician and a nonphysician practitioner (data not shown). A much lower percentage of visits to physicians (30%), PAs (17%), and NPs (38%) were for preventive care. The significance of CHCs as sources of care for the uninsured and underinsured has grown as a result of recent Federally Qualified Health Center (FQHC) expansions and a worsening economy (6-10). NAMCS uses a multistage probability sample design involving geographic primary sampling units (PSUs), physician practices within PSUs, and patient visits within physician practices. Within CHCs, a sample of up to three CHC providers (physicians, PAs, NPs, or CNMs) scheduled to see patients during the sample week was selected, and a random sample of visits during an assigned week was selected for each CHC provider. Differences in visit characteristics for nonphysician clinicians and for physicians were analyzed using Chi-square tests at the p = 0.05 level. These data were imputed (3), but the potential for bias increases as the amount of missing data increases.


Shortages of medical personnel at community health centers: Implications for planned expansion.
Community health center nonphysician practitioner data from the 2006a€“2008 National Ambulatory Medical Care Survey. These people, mostly age 40 and older, took part in one of six population-based studies that were designed to evaluate various aspects of cancer risk.
For example, people who said they got half of the recommended amount of physical activity still added 1.8 years to their life. The relationship between life expectancy and physical activity was stronger among those with a history of cancer or heart disease than among people with no history of cancer or heart disease.
Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis. As the number of CHCs has expanded, demand for both physician and nonphysician practitioner services has increased (2).
About one-third of CHC visits (32%) were by patients of black or other minority racial groups, and one-third (33%) were by Hispanic or Latino patients. Within CHCs, NPs and CNMs disproportionately served young women compared with patients served by physicians, a finding consistent with other national studies (5).
In 2008, visits to CHCs accounted for 14% of all visits to primary care delivery sites by patients with Medicaid or SCHIP as a primary expected source of payment, and 12% of visits by uninsured patients (6). Sampled physicians were selected from the masterfiles of the American Medical Association and the American Osteopathic Association.
To account for the complex sample design during variance estimation, all analyses were performed using the SUDAAN software package, version 9.0 (RTI International, Research Triangle Park, NC).
Vigorous activities are those during which a person could say only a few words without stopping for breath.
This report compares patient and encounter characteristics across the different types of providers seen at CHC visits during a 3-year period, 2006a€“2008. Primary care is recognized as an important strategy for maintaining population health because it is relatively inexpensive, can be more easily delivered than specialty and inpatient care, and if properly distributed could be effective in preventing disease progression on a large scale (11). The present report has documented the roles of nonphysician practitioners in CHCs across the nation from 2006 through 2008. The larger percentage of visits to physicians and PAs by patients for a chronic condition, compared with visits to NPs, is largely attributable to the younger age of patients seen by NPs. PAs, NPs, and CNMs have partnered with physicians and nurses to provide care to a wide spectrum of communities (12,13).
There were no significant differences in types of services provided by physicians, NPs, and PAs, with one exception: PAs and NPs were more likely than physicians to provide or document health education or counseling services at visits. The roles of nonphysician practitioners in CHCs are expected to increase as a result of expanded funding for CHC infrastructure included in the American Recovery and Reinvestment Act of 2009 (14) and additional funding for CHC expansion and health insurance coverage for the uninsured included in the Patient Protection and Affordable Care Act of 2010 (15).
Monitoring CHC utilization and staffing may provide insight into the changing nature of the U.S.



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