Worldwide, current public health programmes and health systems are proving to be inadequate to meet population needs. The microfinance sector offers an underutilized opportunity for delivery of health-related services to many hard-to-reach populations.

Increasingly, patient experience surveys are available to provide performance feedback to physician groups. However, limited published literature addresses factors influencing use of these reports for performance improvement. To address this gap, we conducted semistructured interviews with leaders of Massachusetts physician groups. We asked about factors influencing groups' use of performance data and report characteristics. Motivating characteristics included having group leaders who emphasized a positive patient experience and prioritized patient retention; public reporting was not an important motivator for most groups. Full physician panels were perceived as a barrier to use of reports. Performance reports from a statewide public reporting collaborative were not sufficient for the majority of groups, with many seeking external reports. As policy makers create financial incentives to support performance improvement, assisting leaders to articulate the professional case for patient experience and enhancing the content and timing of performance reports may be important.

Annual Meeting, and the NBER. We are also grateful to Jean Roth and Mohan Ramanujan for assistance obtaining and managing the Medicare claims data. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research. NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of Directors that accompanies official NBER publications.

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IMPORTANCEImproving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits. OBJECTIVE To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics.

| INTRODUC TI ONReferrals from primary care physicians (PCP) to specialists and among different specialists and subspecialists are important contributors to medical care costs and quality. 1,2 Referrals have increased over time, potentially due to the increased complexity of medical care 1 ;research shows PCP referral rates are stable within physician over time, but have significant variation across physicians. 4-6 Referrals contribute to appropriate medical care 1,4 ; better understanding current determinants of referrals and appropriate use is important for improving care delivery, particularly in medically underserved rural areas. 7,8 Access to care and availability of specialists are concerns in rural areas due to distance to providers and the nonrural location of many specialists. 7-10 This results in decreased specialist visits and an increased reliance on PCPs in rural areas. 11The ideal PCP referral rate within and across conditions to optimize patient care to provide the highest quality at the lowest cost is unknown. Referrals may be both over-and under-used by PCPs 12 ; referrals may generate excess spending and increase care fragmentation, but specialists have been shown to be more likely to Abstract Objective: To examine differences in referral patterns in a nationally representative sample between primary care physicians (PCP) practicing in rural vs nonrural areas and changes over time. Study Design: Using the 2005-2016 National Ambulatory Medical Care Survey and multivariate logit regression models, I compare referral patterns of PCPs in rural vs nonrural areas. Data Collection: Multiple years of data were combined.Principal Findings: A PCP visit was 1.9 percentage points (95% confidence interval: 0.1 pp, 3.8 pp) more likely to result in a referral in nonrural areas than rural areas, controlling for physician and patient characteristics, a 17 percent increase. This difference is driven by a widening gap in referral rates between nonrural and rural areas over time, with large differences in later periods. The regression-adjusted predicted probability of a PCP visit resulting in a referral was 71 percent higher in nonrural than rural areas in 2013-2014 and 92 percent higher in 2015-2016. Conclusions:Recognizing that the optimal PCP referral rate is unknown, referrals are less common in rural areas with a widening gap in recent years. This difference may reflect specialist availability, distance to care, or patient preferences. As changes occur to health care financing and delivery, continuing to monitor practice patterns is important to ensure patients are receiving appropriate levels of care across geographic regions. K E Y W O R D S ambulatory care, physician practice patterns, referrals, rural S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section. How to cite this article: Geissler KH. Differences in referral patterns for rural primary care physicians from 2005 to 2016.Health Serv Res. 2020;55:94-102. https ://doi.

IMPORTANCEIn response to increasing public support for cannabis legalization, understanding associations of state and federal policy changes related to cannabis legalization with patterns of cannabis use is important. A challenge for public health monitoring and research is significant variation in data availability related to cannabis use behaviors and perceptions across and within states and over time, including the availability of prelegalization vs postlegalization data. OBJECTIVE To review data available on cannabis use and related behaviors over time in Massachusetts and the US. DESIGN, SETTING, AND PARTICIPANTS This case series examined state and national surveys on public health and related behaviors and outcomes to review availability of cannabis-related data for Massachusetts for 8 key indicators over time. Additionally, the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System for all states were reviewed. The analysis was conducted between February 1, 2019, and March 18, 2020. EXPOSURES Surveys that enable state-level estimation of cannabis use and related behaviors. MAIN OUTCOMES AND MEASURES Eight key indicators related to cannabis use behaviors and perceptions: lifetime cannabis use, age of initiation, frequency of use, location of use, method of use, source of cannabis, perceptions of cannabis, and reason for use (ie, medical vs nonmedical).RESULTS There were 7 surveys that monitored cannabis use and related behaviors in Massachusetts for adolescents and adults. No surveys monitored all 8 indicators of interest, and availability over time was limited. In the most recent BRFSS, 24 states asked cannabis-related questions, meaning BRFSS data on cannabis use was lacking for more than half of the US adult population. In the Youth Risk Behavior Surveillance System, 36 states asked standard cannabis questions; most other states had at least 1 question related to cannabis use and frequency. CONCLUSIONS AND RELEVANCEThese findings of limitations of existing surveys, and particularly the lack of national questions in the BRFSS and Youth Risk Behavior Surveillance System, suggest that available data have substantial limitations for monitoring cannabis use. As cannabis policy changes continue, there is a need to remain focused on the availability of high-quality data sources that allow for critical public health research.

Objective Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content. Research design Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended. Results 90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%). Conclusions Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care.