approximately 80% of the utah population lives on the wasatch front , centering on salt lake city . population growth along the wasatch front has made utah one of the most urban states in the nation . when the ratio of primary care physicians to population is assessed , utah ranks last in the country . there were 89.6 primary care physicians per 100,000 population in the us in 2008 ; massachusetts ranked the highest with 129.4 primary care physicians and utah the lowest , 63.4 . nationally , primary care shortages are predicted as increasing numbers of physicians are selecting specialty practice [ 37 ] . one strategy to address primary care shortages has been to turn to physician assistants ( pas ) . increasing numbers of pas are also entering specialty care although the flexibility and career mobility of pas suggest they can also move out of specialties and into primary care . a utah study in 2006 found there were 4,484 total physicians , which equated to 165 physicians per 100,000 population . in 2003 , 29% of utah physicians were in generalist fields . this study estimated utah would need to recruit up to 270 physicians per year due to population growth , age demographics , loss of full - time equivalent ( fte ) , and retirement . out of state , trained physicians will be required because utah 's medical school will only meet 19%22% of the projected annual demand for physicians . because the governor 's office of planning and budget ( gopb ) projects utah 's overall population to increase from 2.7 million to 3 million by 2012 and another million by 2020 , more doctors may be needed . according to the us census bureau , utah was the second fastest growing state in the nation during 2009 with an annual growth rate of 2.1% . the number of utahans over age 65 ( as a percentage of the population ) is expected to increase with estimates that the age 65 and older population will grow from 213,201 in 2000 to 319,564 in 2015 ( a growth rate of 50% ) . the demographics of utah are unique , ranking first in the country for population growth ( due almost entirely to a high fertility rate ) . more than 20% of the population are dependent children , stretching public services including public schools and health care . three factors  high fertility rate , growing elderly , and increased utilization of health care services  are expected to increase the demand for primary care services . since the turn of the new century , workforce studies have focused on the increasing supply of pas in the state . in utah , the visibility of pas has been increasing . from 2003 to 2008 , the number of pas has grown from 324 active pa licenses to 700 active pa licenses ( 116% growth ) .   to better understand the current distribution of pas , along with the enablers and barriers to primary care and rural practice selection what are the factors associated with primary care and rural practice selection ?   can pas help address the increasing need for primary care providers in utah by choosing primary care specialties ? a list of licensed pas was obtained through the utah department of commerce 's division of professional licensing ( dopl ) . in 2008 , there were 700 licensed pas in the state ; a survey was sent to every pa . a total of three separate mailings were conducted over the period of october 2008 through january 2009 . of the 474 respondents , 432 pas said they are actively practicing in utah ( 90.7% ) . survey responses were not weighted for nonrespondents for the purpose of the regression analysis . when checked for potential response biases based on year of licensure , age , gender , and geography , a particularly low response rate was identified for iron county , a rural county located in southwest utah . targeted mailings to the pas with addresses located in iron county a survey instrument was constructed based on two previous surveys ( 1998 and 2003 ) and a physician workforce survey ( 2006 ) . a pa study committee included the university of utah pa program director , the executive director of the utah academy of physician assistants , and three practicing pas . the study population was the universe of pas licensed to practice in utah in october 2008 . pas were categorized as primary care if their self - reported specialty was family practice , general internal medicine , pediatrics , or obstetrics and gynecology . cache , davis , provo , salt lake , weber , and washington county were considered urban ; 20 of the 26 counties were classified as rural . utah has 5 urban communities , salt lake , logan , ogden , provo , and st . multinomial logistic regression analysis was performed using spss 16.0 to assess the relationship of the predictive variable to the outcome of rural and/or primary care practice , using odds ratios with 95% confidence intervals ( cis ) . responses were obtained from 432 of 700 physician assistants who are actively practicing in the state of utah ( table 1 ) . thirty - six percent of utah pas are between the ages of 31 and 40 years , with males at 60.6% of the total respondents . nearly half ( 47.4% ) of the respondents have been in practice between 0 and 5 years . nearly half ( 47.6% ) of the respondents graduated from the university of utah physician assistant program . forty - five percent of physician assistants in utah provide primary care and 85.3% practice in an urban location . except for washington county , all of the counties with greater than 40% nonresponse rate were counties with fewer than 10 pas in them . the only county with more than 5 pas and greater than 50% nonresponse rate was iron county . a targeted separate mailing was sent to iron county pas in order to attempt to increase response rates ( table 2 ) . increasing age and years of license resulted in slightly higher response rates ( table 3 ) . in logistic regression analysis , pas age 3140 had the highest odds of practicing in primary care ( or : 1.74 ; 95% ci : 0.853.57 ) female pas had lower odds of practicing in primary care versus their male counterparts ( or : 0.56 ; 95% ci : 0.330.96 ) . pas had lower odds of practicing primary care if they reported a rural or suburban upbringing ( or 0.49 ; 95% ci : 0.260.93 , and or : 0.33 ; 95% ci : 0.160.66 ) . graduation from the utah pa program was more likely to result in primary care practice ( or 2.16 ; 95% ci : 1.343.49 ) . the only statistically significant predictors of primary care practice were being male ( p = 0.036 ) , obtaining training in the state of utah ( p = 0.002 ) , and urban upbringing ( p = 0.008 ) . in logistic regression analysis , female pas had lower odds of practicing in a rural area ( or : 0.26 ; 95% ci : 0.100.66 , p = 0.005 ) ( table 5 ) . pas who reported graduating from the utah physician assistant program had higher odds of practicing in a rural area ( or : 1.33 ; 95% ci : 0.672.65 , p = 0.413 ) , but this did not achieve statistical significance . pas who practiced in a rural environment were more likely to report a rural upbringing ( or : 2.29 ; 95% ci : 0.895.85 , p = 0.001 ) . the only statistically significant factors were male gender ( p = 0.005 ) and rural upbringing ( p = 0.001 ) . age and years of practice were not significantly associated with predictors of rural practice in utah . from 2003 to 2008 , specialty practice choice of family medicine declined from 40% to 31.5% of the total utah pa workforce ( table 6 ) . pas in utah mirror the changing workforce demographics of the state : young , primarily urban , and suburban - raised professionals . under the current scenario , the potential use of pas to blunt predicted rural and primary care shortages of utah physicians may fall short . within the last 10 years , utah has increasingly relied on pas trained in other states because the state 's pa program of 40 pas graduates per year is insufficient . in 2008 , a total of 88 pas practiced in rural counties , consisting of 21.6% ( 19 ) female pas and 78.4% ( 69 ) male pas . efforts are underway to bolster the nation 's primary care workforce , and the patient protection affordable care act ( ppaca ) legislation of 2010 injects $ 250 million to improve primary care education for doctors , pas and nps . however , primary care may not be possible without incentives to practice in this specialty because salary was not independently predictive of either rural or specialty practice , nor were years of practice . influencing factors upon primary care and/or rural practice include loan repayment and tax incentives  strategies that have been employed with success in other states . although many pas have been shifting into specialty practice , primary care still remains a viable choice for many pas entering the workforce . the finding that female pas may be more likely to practice in specialty care may be due to the increased job availability of specialty care in recent years . pas may be different from their physician counter parts when it comes to specialty choices . utah pas were twice as likely to practice in a rural environment if they reported being raised in a rural community . male gender has been significantly associated with rural practice and is reflected in this research . although utah has been traditionally male dominated pa profession , this is slowly changing . on average , the pa workforce in utah graduated from a pa training program 15 years ago ( median of 8 years ) . the mean number of years of experience for male pas is much higher than for females there are 21.3% ( 79 ) of male pas in the utah workforce with over 20 years of experience , whereas only 6.1% ( 15 ) of female pas have greater than 20 years of experience .   in this study , rural location of upbringing was associated with statistically significant lower odds of practicing in primary care when compared to urban location of upbringing . one possible explanation is the overall increase in urban location of many primary care practice jobs . in general , the results of this study showed increased urbanization of the young profession . this is higher than the american academy of physician assistants ( aapa ) survey 2009 response rate of 35% . effort was made to locate the pa practice location , not the home address in the analysis , and zip codes were used to classify county of practice . because utah has a clear pocket of urban living on the western slope of the wasatch mountains and one more pocket in the southern end of the state , and given the small number of pas in the state , finer zip code detail in the analysis did not result in a more informative study . a second limitation of the study was the self - classification of rural , urban , and suburban upbringing . because of the changing nature of rurality in the state and the age of the person answering the question , it was decided that self - classification was the method to employ . in this case , perception may be reality , and primarily for the sake of simplicity , this method , which has been employed in other similar studies , was utilized . finally , the classification of rural , urban , and suburban was used in the survey to improve the self - reporting of upbringing , although the analysis only used rural or urban in reporting outcomes . factors such as rural , urban , or suburban upbringing , gender , age , and years of practice are important as they relate to primary care and rural health care practice among pas in utah . a consistent and well - trained supply of pas is critical to access to care for utah citizens . our findings suggest utah will continue to experience shortages of primary care physicians that will be amplified in underserved and rural communities . substantially increasing the number of pas practicing in these areas may require a number of strategies that take into consideration demographic as well as personal factors . rural versus urban practice choice among pas in utah could potentially be influenced by recruitment , training , and retention efforts that facilitate workforce placement in critical areas . key groups and leaders in primary care and rural health care could be canvassed as to how to implement effective strategies to influence pas to enter primary care and/or rural practice . for example , county commissioners , small town majors , rural hospital administrators , and local health department employees may have special interests and expertise in pa recruitment and mentoring . an absence of proactive strategies may be an opportunity missed as the path toward increasing specialization and urbanization has been well worn .
physician assistants ( pas ) have become an integral part of the united states ( u.s . ) health care system since the profession began in the late 1960s . 
 pas have been suggested as solutions to predicted physician shortages especially in primary care . 
 this study examined the predictors of primary care and rural practice patterns of pas in utah . 
 a cross sectional survey design was utilized . 
 the outcome variables were practice specialty and practice location . 
 the predictor variables were age , gender , number of years in practice , location of upbringing , and professional school of graduation . 
 there was a response rate of 67.7% . 
 the utah division of occupational and professional licensing ( dopl ) provided the list of licensed pas in the state . 
 physician assistants who reported being raised in rural communities were 2.29 times more likely to be practicing in rural communities ( 95% ci 0.895.85 ) . 
 female pas had lower odds of practicing in a rural area ( or : 0.26 ; 95% ci : 0.100.66 ) . 
 female pas had lower odds of practicing in primary care versus their male counterparts ( or : 0.56 ; 95% ci : 0.330.96 ) . 
 graduation from the utah pa program was more likely to result in primary care practice ( or : 2.16 ; 95% ci : 1.343.49 ) .