Practice Patterns, Work Environments, and Job Outcomes of Rural and Urban Primary Care Nurse Practitioners

As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.

Misalignment of specialty nurse practitioners and the Consensus Model

Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.

Pediatric Outcomes After Regulatory Mandates for Sepsis Care

BACKGROUND

In 2013, New York introduced regulations mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment.

METHODS

We used hospital discharge data from 2011 to 2015 to compare changes in pediatric sepsis outcomes in New York and 4 control states: Florida, Massachusetts, Maryland, and New Jersey. We examined the effect of the New York regulations on 30-day in-hospital mortality using a comparative interrupted time-series approach, controlling for patient and hospital characteristics and preregulation temporal trends.

RESULTS

We studied 9436 children admitted to 237 hospitals. Unadjusted pediatric sepsis mortality decreased in both New York (14.0% to 11.5%) and control states (14.4% to 11.2%). In the primary analysis, there was no significant effect of the regulations on mortality trends (differential quarterly change in mortality in New York compared with control states: -0.96%; 95% confidence interval [CI]: -1.95% to 0.02%; P = .06). However, in a prespecified sensitivity analysis excluding metropolitan New York hospitals that participated in earlier sepsis quality improvement, the regulations were associated with improved mortality trends (differential change: -2.08%; 95% CI: -3.79% to -0.37%; P = .02). The regulations were also associated with improved mortality trends in several prespecified subgroups, including previously healthy children (differential change: -1.36%; 95% CI: -2.62% to -0.09%; P = .04) and children not admitted through the emergency department (differential change: -2.42%; 95% CI: -4.24% to -0.61%; P = .01).

CONCLUSIONS

Implementation of statewide sepsis regulations was generally associated with improved mortality trends in New York State, particularly in prespecified subpopulations of patients, suggesting that the regulations were successful in affecting sepsis outcomes.

Practice Expenses Associated with Comprehensive Primary Care Capabilities

Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care.

Effects of opting-out from federal nurse anesthetists' supervision requirements on anesthesiologist work patterns

OBJECTIVE

To estimate the impact of opting-out from Medicare supervision requirements for certified registered nurse anesthetists (CRNAs) on anesthesiologists' work patterns.

DATA SOURCES/STUDY SETTING

Secondary data from two national surveys of anesthesiologists and the Area Health Resource File.

STUDY DESIGN

We use a matching difference-in-difference regression which contrasts the change in work patterns for anesthesiologists in California, which dropped supervision requirements, to the change for similar anesthesiologists. Key outcome variables include the number of weekly hours worked, the type of work done, and type of care delivery teams.

DATA COLLECTION/EXTRACTION METHODS

Self-reported national survey data drawn from members of the American Society of Anesthesiologists.

PRINCIPAL FINDINGS

Anesthesiologists in California saw no change in time spent working or time spent supervising CRNAs. There was a decrease in direct care clinical work hours along with a shift in working more in intraoperative care, a decrease in postoperative care, and an increase in the percentage of cases supervising residents.

CONCLUSIONS

Anesthesiologists had small but real responses to California's decisions to opt-out of the physician supervision requirement for CRNAs, doing more work in intraoperative care and less outside of the operating room. Total hours worked saw no change.

Work Performance Among Informal Caregivers: A Review of the Literature

Objectives: To examine the association between informal caregiving and caregiver work performance. Method: A systematized review of the literature. Results: We found that caregiving has an adverse impact on work performance: caregivers experience substantial work disruptions and negative work performance outcomes, and these findings were consistent across measures. Our synthesis suggests that caregivers miss a significant amount of work and have reductions in productivity due to their caregiving responsibilities. However, significant methodological limitations with the reviewed studies make systematic interpretations and causal determinations challenging. Discussion: Examining the effect of caregiving on work performance is critical to better understand the full impact of caregiving, especially as demand for caregivers increases as the population ages. This comprehensive review suggests that caregiving has a significant negative impact on work performance, although methodological challenges remain in this area of science. These findings should inform both public policy development and workplace benefits design.

Nurse Practitioner Scope of Practice Regulations and Nurse Practitioner Supply

Adopting full scope of practice (SOP) for nurse practitioners (NPs) is associated with improved access to care. One possible mechanism for these improvements is increased NP supply. Using county-level data, we fit cross-sectional and panel regression models to estimate the association between adopting full NP SOP and NP supply in general, and in rural and health professional shortage area-designated counties in particular. In cross-sectional analyses, we estimated positive associations between NP SOP and NP supply, though these relationships were only statistically significant when analyzing health professional shortage areas. In the panel regression models with county fixed effects, the estimated effects were attenuated toward zero and sometimes switched signs. Our findings suggest that improvements in access to care following adoption of full SOP may not be driven by increased NP supply but rather by increased capacity of NPs and physicians to provide care.

The Need for Advanced Clinical Education for Nurse Practitioners Continues Despite Expansion of Doctor of Nursing Practice Programs

We read with great interest Mundinger and Carter's exposition of how, in their view, Doctor of Nursing Practice (DNP) education has lost its way and what consequences might result. Mundinger and Carter note that DNP programs are overwhelming focused on nonclinical practice. We share the concern of Mundinger and Carter about the future of nurse practitioner (NP) education within the context of expanding DNP programs. In this commentary, we raise concerns about NP transition to practice and the limited, but concerning, evidence that new NPs struggle in their transition to practice. We note that this concern is magnified as NPs continue to move into specialty roles. Health systems have responded to this concern by developing residency and fellowship programs. Fifteen years after the AACN position statement on the clinical doctorate was issued, the goal of DNP education remains an unfinished project. An important question remains: Can, will, and how should DNP programs deliver?

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers

BACKGROUND AND OBJECTIVES

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie.

RESEARCH DESIGN AND METHODS

A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature.

RESULTS

Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed.

DISCUSSION AND IMPLICATIONS

The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis

IMPORTANCE

Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown.

OBJECTIVE

To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach.

EXPOSURES

Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay.

RESULTS

The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001).

CONCLUSIONS AND RELEVANCE

In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.

Is a culture of health always healthy?

Health care systems in the United States are increasingly focused on addressing the social and cultural determinants of health (ie, a biopsychosocial model of disease). We applaud this important and laudable shift within US healthcare, which has long been dominated by a merely biomedical model of disease. However, we offer three reasons for nurses and other healthcare providers to proceed with caution; otherwise, human culture could become merely a tool of the healthcare industry to be instrumentally deployed in meeting its procedural goals.

Estimating the Costs of Implementing Comprehensive Primary Care: A Narrative Review

The performance of the any health-care system relies on a high-functioning primary care system. Increasing primary care practices' adoption of "comprehensive primary care" capabilities might yield meaningful improvements in the quality and efficiency of primary care. However, many comprehensive primary care capabilities, such as care management and coordination, are not compensated via traditional fee-for-service payment. To calculate new payments for these capabilities, policymakers would need estimates of the costs that practices incur when adopting, maintaining, and using the capabilities. We performed a narrative review of the existing literature on the costs of adopting and implementing comprehensive primary care capabilities. These studies have found that practices incur significant costs when adopting and implementing comprehensive primary care capabilities. However, the studies had significant limitations that prevent extensive use of their estimates for payment policy. Particularly, the strongest studies focused on a small numbers of practices in specific geographic areas and the concepts and methods used to assess costs varied greatly across the studies. Furthermore, none of the studies in our review attempted to estimate differences in costs across practices with patients at varying levels of complexity and illness burden which is important for risk-adjusting payments to practices. Therefore, due to the heterogeneous designs and limited generalizability of published studies highlight the need for additional research, especially if payers wish to link their financial support for comprehensive primary care capabilities to the costs of these capabilities for primary care practices.

Linking Structural Capabilities and Workplace Climate in Community Health Centers

Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = −0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = −0.48, P = .015) and less proactive patient outreach (β = −1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs.

Integrating Political Philosophy Into Health Policy Education

Twenty-first century America is marked by deep and seemingly incommensurable divisions in terms of public policy solutions to our most intractable issues. Health policy challenges are not immune to these deep divisions, as the debate during and since the passage of the Affordable Care Act illustrates. Positions on key public policy issues are driven by largely implicit and unarticulated philosophical presuppositions that guide individuals' notions of the nature of government, individuals' moral obligations to each other, how society assesses quality of life, and what it means to be a community. If faculty in schools of nursing are to prepare graduate nurses to enter into these heated public policy debates, we must help students understand, identify, and articulate the philosophical presuppositions that undergird reasoning related to health policy issues. In this article, we present a working taxonomy that can help faculty members provide students with a basic understanding of core philosophical principles. We attempt to categorize all of western political philosophy into four distinct traditions or "impulses," describing each of these four traditions in detail. We illustrate each tradition's approach to political reasoning using a specific health policy case study. We conclude with some guidance about how to implement this content within a doctoral-level public policy curriculum.

Employment of Advanced Practice Clinicians in Physician Practices

This study examines trends in advanced practice clinician employment across different physician practices in the United States.

Primary Care Nurse Practitioner Practice Characteristics: Barriers and Opportunities for Interprofessional Teamwork

Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and NP-administration relationships; organizational support and governance; time and space for teamwork; and regulations and economic impact as important. Practice and policy change addressing these factors is needed for effective interprofessional teamwork.

Changing Structures and Processes to Support Family Caregivers of Seriously Ill Patients

BACKGROUND

Although family caregivers provide a significant portion of health and support services to adults with serious illness, they are often marginalized by existing healthcare systems and procedures.

OBJECTIVE

We examine the role of caregivers in existing systems of care, identify needed changes in structures and processes, and describe how these changes might be monitored and assessed and who should be accountable for implementing them.

DESIGN

Based on a broad assessment of the caregiving literature, the recent National Academy of Sciences Report on family caregiving, and descriptive data from two national surveys, we describe structural and process barriers that limit caregivers' ability to provide effective care.

SUBJECTS

To describe the unique challenges and impacts of caring for seriously ill patients, we report data from a nationally representative sample of older adults and their caregivers (National Health and Aging Trends Study [NHATS]; National Study of Caregiving [NSOC]) to identify the prevalence and impact on family caregivers of seriously ill patients who have high needs for support and are high cost to the healthcare system.

MEASUREMENTS

Standardized measures of patient status and caregiver roles and impacts are used.

RESULTS

Multiple structural and process barriers limit the ability of caregivers to provide effective care. These issues are exacerbated for the more than 13 million caregivers who provide care and support to 9 million seriously ill older adults.

CONCLUSIONS

Fundamental changes are needed in the way we identify, assess, and support caregivers. Educational and workforce development reforms are needed to enhance the competencies of healthcare and long-term service providers to effectively engage caregivers.

Association Between Sponsorship and Findings of Medical Home Evaluations

This analysis of published evaluations of medical home interventions investigates whether there is an association between the findings and whether the evaluators were employed or funded by intervention sponsors.

Trends in Visits to Specialist Physicians Involving Nurse Practitioners and Physician Assistants, 2001 to 2013

This study describes the roles of nurse practitioners and physician assistants in providing care to specialist physicians’ patients.