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Thompson S, Moorley C, Barratt J. A comparative study on the clinical decision-making processes of nurse practitioners vs. medical doctors using scenarios in a secondary care environment. J Adv Nurs 2016; 73:1097-1110. [PMID: 27859497 DOI: 10.1111/jan.13206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/29/2022]
Abstract
AIM To investigate the decision-making skills of secondary care nurse practitioners compared with those of medical doctors. BACKGROUND A literature review was conducted, searching for articles published from 1990 - 2012. The review found that nurse practitioners are key to the modernization of the National Health Service. Studies have shown that compared with doctors, nurse practitioners can be efficient and cost-effective in consultations. DESIGN Qualitative research design. METHODS The information processing theory and think aloud approach were used to understand the cognitive processes of 10 participants (5 doctors and 5 nurse practitioners). One nurse practitioner was paired with one doctor from the same speciality and they were compared using a structured scenario-based interview. To ensure that all critical and relevant cues were covered by the individual participating in the scenario, a reference model was used to measure the degree of successful diagnosis, management and treatment. This study was conducted from May 2012 - January 2013. RESULTS The data were processed for 5 months, from July to November 2012. The two groups of practitioners differed in the number of cue acquisitions obtained in the scenarios. In our study, nurse practitioners took 3 minutes longer to complete the scenarios. CONCLUSION This study suggests that nurse practitioner consultations are comparable to those of medical doctors in a secondary care environment in terms of correct diagnoses and therapeutic treatments. The information processing theory highlighted that both groups of professionals had similar models for decision-making processes.
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Affiliation(s)
- Stephen Thompson
- School of Health & Social Care, London South Bank University, UK
| | - Calvin Moorley
- School of Health & Social Care, London South Bank University, UK
| | - Julian Barratt
- Faculty of Education, Health and Wellbeing, University of Wolverhamptom, UK
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Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227. [PMID: 27873322 PMCID: PMC6464275 DOI: 10.1002/14651858.cd011227.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Affiliation(s)
- Greg Weeks
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
- Barwon HealthPharmacy DepartmentGeelongVictoriaAustralia
| | - Johnson George
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
| | - Katie Maclure
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
| | - Derek Stewart
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
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Scott PJ, Curley PJ, Williams PB, Linehan IP, Shaha SH. Measuring the operational impact of digitized hospital records: a mixed methods study. BMC Med Inform Decis Mak 2016; 16:143. [PMID: 27829453 PMCID: PMC5103462 DOI: 10.1186/s12911-016-0380-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 11/01/2016] [Indexed: 11/22/2022] Open
Abstract
Background Digitized (scanned) medical records have been seen as a means for hospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity. Methods Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which pre-defined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized. Results Four hundred six consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p = 0.016) and a significant difference in consultation times between specialties within hospitals (p = 0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p = 0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p > =0.285) or specialty level (p > =0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (p < =0.010, Δ = 01:50–07:10) and one specialty had a corresponding reduction in time spent searching paper records (p = 0.015, Δ = −00:28). Site B showed a notable increase in direct patient care (p < 0.001, Δ = 04:20–06:00) and time spent searching computer records (p < =0.043, Δ = 00:10–01:40) and reductions in the other time categories. The focus group confirmed that the most recent clinical letter was a vital document in the patient record, often containing most of the required information. Concerns were expressed about consistency of scanning practice, causing uncertainty about what could be relied upon to exist in the digitized record. Benefits of digitized records included: access from multiple locations, better prepared ward rounds, improved inpatient handovers and an improved timeline of patient events. Limitations of digitized records included: increased complexity of creating a patient summary, display of specialised content such as hand-drawn diagrams, inability to quickly flick through the pages to find relevant content. Conclusions Digitized medical records can be implemented without detrimental operational impact. Inherent differences between specialties can outweigh the differences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.
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Affiliation(s)
- Philip J Scott
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK.
| | - Paul J Curley
- The Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Aberford Road, Wakefield, WF1 4DG, UK
| | - Paul B Williams
- EDM Project Manager, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
| | - Ian P Linehan
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon, Essex, SS16 5NL, UK
| | - Steven H Shaha
- Center for Public Policy and Administration, University of Utah, Salt Lake City, UT, 84112, USA
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Van Der Biezen M, Adang E, Van Der Burgt R, Wensing M, Laurant M. The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasi-experimental study. BMC FAMILY PRACTICE 2016; 17:132. [PMID: 27619968 PMCID: PMC5020461 DOI: 10.1186/s12875-016-0528-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
Background The pressure in out-of-hours primary care is high due to an increasing demand for care and rising health-care costs. During the daytime, substituting general practitioners (GPs) with nurse practitioners (NPs) shows positive results to contribute to these challenges. However, there is a lack of knowledge about the impact during out-of-hours. The current study aims to provide an insight into the impact of substitution on resource use, production and direct health-care costs during out-of-hours. Methods At a general practitioner cooperative (GPC) in the south-east of the Netherlands, experimental teams with four GPs and one NP were compared with control teams with five GPs. In a secondary analysis, GP care versus NP care was also examined. During a 15-month period all patients visiting the GPC on weekend days were included. The primary outcome was resource use including X-rays, drug prescriptions and referrals to the Emergency Department (ED). We used logistic regression to adjust for potential confounders. Secondary outcomes were production per hour and direct health-care costs using a cost-minimization analysis. Results We analysed 6,040 patients in the experimental team (NPs: 987, GPs: 5,053) and 6,052 patients in the control team. There were no significant differences in outcomes between the teams. In the secondary analysis, in the experimental team NP care was associated with fewer drug prescriptions (NPs 37.1 %, GPs 43 %, p < .001) and fewer referrals to the ED (NPs 5.1 %, GPs 11.3 %, p = .001) than GP care. The mean production per hour was 3.0 consultations for GPs and 2.4 consultations for NPs (p < .001). The cost of a consultation with an NP was €3.34 less than a consultation with a GP (p = .02). Conclusions These results indicated no overall differences between the teams. Nonetheless, a comparison of type of provider showed that NP care resulted in lower resource use and cost savings than GP care. To find the optimal balance between GPs and NPs in out-of-hours primary care, more research is needed on the impact of increasing the ratio of NPs in a team with GPs on resource use and health-care costs. Trial registration ClinicalTrials.gov ID NCT01388374.
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Affiliation(s)
- Mieke Van Der Biezen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Eddy Adang
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Regi Van Der Burgt
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, 5652 NP, Eindhoven, The Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of General Practice and Health Services Research, Heidelberg University, INF Marsilius Arkaden, Heidelberg, Germany
| | - Miranda Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, P.O. Box 6960, 6503 GL, Nijmegen, The Netherlands
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Roberts C, Roberts SA. Design and analysis of clinical trials with clustering effects due to treatment. Clin Trials 2016; 2:152-62. [PMID: 16279137 DOI: 10.1191/1740774505cn076oa] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Where patients receive therapy as a group, there are good theoretical reasons to believe that variation in the outcome will be smaller for patients treated in the same group than for patients treated in different groups. Similarly, where different therapists treat different groups of patients, outcome for patients treated by the same therapist may differ less than outcome for patients treated by different therapists. Clinical trials evaluating such therapies need to consider this potential lack of independence. As with cluster-randomized trials, this has implications for the precision of treatment effects estimates and statistical power. There are nevertheless differences between clustering due to the organization of treatment and that due to randomization. In cluster-randomized trials the distribution of cluster sizes in each treatment arm should be similar as a consequence of randomization unless there is differential loss to follow-up. With clustering due to therapy group or therapist, cluster size may differ systematically between treatment arms, due to size of therapy groups or differing health professional caseload. Intra-cluster correlation may also differ between treatment arms. The implications of differential cluster size and intracluster correlation for design and analysis will be illustrated by data from two trials, the first comparing nurse practitioner care with general practitioner care, and the second comparing a group therapy with individual treatment as usual. The special case where a group therapy or therapist is compared with an unclustered treatment is examined in detail using a simulation study. The implications of differential clustering effects for sample size and power are addressed. It is argued that the design and analysis of this type of trial should take account of possible heterogeneity in cluster size and intracluster correlation.
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Affiliation(s)
- Chris Roberts
- Biostatistics Group, Division of Epidemiology and Health Sciences, University of Manchester, UK.
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Abstract
The current political healthcare economy is blurring traditional professional bound aries, and national agendas are requiring nurses to take on more roles and tasks previously undertaken by doctors. The emergency nurse practitioner’s expanding scope of practice has moved beyond managing the care of patients with minor injuries, to include those with ‘minor’ illnesses and indeed beyond that to the management and care of those with increasingly complex, acute and chronic conditions. The process of conjugation between the two disciplines has been driven by the demands and pressures on the health economy. Given the unprecedented and increasing overlap in practice between the domains of medicine and nursing, it is time to re-examine differences between them and clarify the issues which divide them. There is a need to benchmark infrastructure and standardize the education and development of nurses undertaking advanced practice roles. There is also a need for continued debate on the future of the health care workforce, informed by research, to facilitate correct and cost effective decision making.
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Affiliation(s)
- Simon Brook
- University of Southampton and Southampton Walk In Centres, Southampton, UK,
| | - Robert Crouch
- Emergency Department, Southampton University NHS Trust, School of Nursing and Midwifery, University of Southampton, Southampton, UK
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de Lusignan S, McGovern AP, Tahir MA, Hassan S, Jones S, Halter M, Joly L, Drennan VM. Physician Associate and General Practitioner Consultations: A Comparative Observational Video Study. PLoS One 2016; 11:e0160902. [PMID: 27560179 PMCID: PMC4999215 DOI: 10.1371/journal.pone.0160902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/20/2016] [Indexed: 11/18/2022] Open
Abstract
Background Physician associates, known internationally as physician assistants, are a mid-level practitioner, well established in the United States of America but new to the United Kingdom. A small number work in primary care under the supervision of general practitioners, where they most commonly see patients requesting same day appointments for new problems. As an adjunct to larger study, we investigated the quality of the patient consultation of physician associates in comparison to that of general practitioners. Method We conducted a comparative observational study using video recordings of consultations by volunteer physician associates and general practitioners with consenting patients in single surgery sessions. Recordings were assessed by experienced general practitioners, blinded to the type of the consulting practitioner, using the Leicester Assessment Package. Assessors were asked to comment on the safety of the recorded consultations and to attempt to identify the type of practitioner. Ratings were compared across practitioner type, alongside the number of presenting complaints discussed in each consultation and the number of these which were acute, minor, or regarding a chronic condition. Results We assessed 62 consultations (41 general practitioner and 21 physician associates) from five general practitioners and four physician associates. All consultations were assessed as safe; but general practitioners were rated higher than PAs in all elements of consultation. The general practitioners were more likely than physician associates to see people with multiple presenting complaints (p<0.0001) and with chronic disease related complaints (p = 0.008). Assessors correctly identified general practitioner consultations but not physician associates. The Leicester Assessment Package had limited inter-rater and intra-rater reliability. Conclusions The physician associate consultations were with a less complex patient group. They were judged as competent and safe, although general practitioner consultations, unsurprisingly, were rated as more competent. Physician associates offer a complementary addition to the medical workforce in general practice.
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Affiliation(s)
- Simon de Lusignan
- Department of Clinical and Experimental Medicine University of Surrey, Guildford, GU2 7XH, United Kingdom
- Division of Population Health Sciences and Education St. George’s University of London, London, SW17 0RE, United Kingdom
- * E-mail:
| | - Andrew P. McGovern
- Department of Clinical and Experimental Medicine University of Surrey, Guildford, GU2 7XH, United Kingdom
| | - Mohammad Aumran Tahir
- Department of Clinical and Experimental Medicine University of Surrey, Guildford, GU2 7XH, United Kingdom
- AT Medics, St. Charles Hospital, Exmoor Street, London, W10 6DZ, United Kingdom
| | - Simon Hassan
- Department of Clinical and Experimental Medicine University of Surrey, Guildford, GU2 7XH, United Kingdom
| | - Simon Jones
- Department of Clinical and Experimental Medicine University of Surrey, Guildford, GU2 7XH, United Kingdom
- Department of Population Health NYU School of Medicine, 227 East 30th Street, New York, New York, 10016, United States of America
| | - Mary Halter
- Faculty of Health, Social Care & Education, Kingston University & St. George’s University of London, London, United Kingdom
| | - Louise Joly
- Social Care Workforce Research Unit King’s College London, Strand, London, WC2R 2LS, United Kingdom
| | - Vari M. Drennan
- Faculty of Health, Social Care & Education, Kingston University & St. George’s University of London, London, United Kingdom
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Abstract
This paper discusses the dynamic effects on nursing of a changing health service. Scotland's demography presents the profession with unique challenges around securing future services. The Government in Scotland's response has focused on increasing workforce numbers. Workforce dynamics will, however, impact on nursing workforce numbers as all public sector employers compete for a contracting pool of resource. Reserved UK powers for professional regulation and devolved Scottish powers for health and education, matched with specific Scottish laws, can facilitate the development of new roles and new ways of working. Many examples of role development exist and some are provided here.
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Affiliation(s)
- Audrey Cowie
- Centre for Change and Innovation, Scottish Executive Health Department
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Latter S, Maben J, Myall M, Young A, Baileff A. Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations. J Res Nurs 2016. [DOI: 10.1177/1744987106073949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study. Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices. Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written ( n =132) by nurses and b) the record of the prescribing episode in patient records ( n =118). Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England. Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records. Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.
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Affiliation(s)
- Sue Latter
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Jill Maben
- Health Services Research Unit, London School of Hygiene and Tropical Medicine
| | - Michelle Myall
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Amanda Young
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton
| | - Anne Baileff
- Southampton City PCT/School of Nursing and Midwifery
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Martin-Misener R, Kilpatrick K, Donald F, Bryant-Lukosius D, Rayner J, Valaitis R, Carter N, Miller PA, Landry V, Harbman P, Charbonneau-Smith R, McKinlay RJ, Ziegler E, Boesveld S, Lamb A. Nurse practitioner caseload in primary health care: Scoping review. Int J Nurs Stud 2016; 62:170-82. [PMID: 27494430 DOI: 10.1016/j.ijnurstu.2016.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 05/20/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To identify recommendations for determining patient panel/caseload size for nurse practitioners in community-based primary health care settings. DESIGN Scoping review of the international published and grey literature. DATA SOURCES The search included electronic databases, international professional and governmental websites, contact with experts, and hand searches of reference lists. Eligible papers had to (a) address caseload or patient panels for nurse practitioners in community-based primary health care settings serving an all-ages population; and (b) be published in English or French between January 2000 and July 2014. Level one testing included title and abstract screening by two team members. Relevant papers were retained for full text review in level two testing, and reviewed by two team members. A third reviewer acted as a tiebreaker. Data were extracted using a structured extraction form by one team member and verified by a second member. Descriptive statistics were estimated. Content analysis was used for qualitative data. RESULTS We identified 111 peer-reviewed articles and grey literature documents. Most of the papers were published in Canada and the United States after 2010. Current methods to determine panel/caseload size use large administrative databases, provider work hours and the average number of patient visits. Most of the papers addressing the topic of patient panel/caseload size in community-based primary health care were descriptive. The average number of patients seen by nurse practitioners per day varied considerably within and between countries; an average of 9-15 patients per day was common. Patient characteristics (e.g., age, gender) and health conditions (e.g., multiple chronic conditions) appear to influence patient panel/caseload size. Very few studies used validated tools to classify patient acuity levels or disease burden scores. DISCUSSION The measurement of productivity and the determination of panel/caseload size is complex. Current metrics may not capture activities relevant to community-based primary health care nurse practitioners. Tools to measure all the components of these role are needed when determining panel/caseload size. Outcomes research is absent in the determination of panel/caseload size. CONCLUSION There are few systems in place to track and measure community-based primary health care nurse practitioner activities. The development of such mechanisms is an important next step to assess community-based primary health care nurse practitioner productivity and determine patient panel/caseload size. Decisions about panel/caseload size must take into account the effects of nurse practitioner activities on outcomes of care.
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Affiliation(s)
- Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Ave., Halifax, NS, B3H 4R2, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montréal, Research Center Hôpital Maisonneuve-Rosemont CSA-RC-Aile bleue-Bureau F121, 5415 boul. l'Assomption, Montréal, QC H1T 2M4, Canada
| | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria St., Toronto, ON M5B 2K3, Canada
| | - Denise Bryant-Lukosius
- School of Nursing & Dept. of Oncology, McMaster University, FHS-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Jennifer Rayner
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria St., Toronto, ON M5B 2K3, Canada
| | - Ruta Valaitis
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Patricia A Miller
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Véronique Landry
- Faculty of Nursing, Université de Montréal, Research Center Hôpital Maisonneuve-Rosemont CSA-RC-Aile bleue-Bureau F121, 5415 boul. l'Assomption, Montréal, QC H1T 2M4, Canada
| | - Patricia Harbman
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria St., Toronto, ON M5B 2K3, Canada
| | - Renee Charbonneau-Smith
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - R James McKinlay
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Erin Ziegler
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria St., Toronto, ON M5B 2K3, Canada
| | - Sarah Boesveld
- School of Nursing, McMaster University, HSC-3N28G, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada
| | - Alyson Lamb
- School of Nursing, Dalhousie University, Box 15000, 5869 University Ave., Halifax, NS, B3H 4R2, Canada
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Raji MY, Chen NW, Raji M, Kuo YF. Factors Associated With Seeking Physician Care by Medicare Beneficiaries Who Receive All Their Primary Care From Nurse Practitioners. J Prim Care Community Health 2016; 7:249-57. [PMID: 27456894 DOI: 10.1177/2150131916659674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A shortage of primary care physicians has led to the alternative strategy of nurse practitioners (NPs) as primary care providers for the growing elderly population. Many states have implemented policies that allow NPs to practice independently with no physician oversight. Little is known about the continuity of primary care provided by NPs. OBJECTIVE To examine rate and correlates of switching from exclusive NP primary care to receiving some or all primary care from physicians. DESIGN A retrospective cohort study. PARTICIPANTS Medicare beneficiaries (n = 38 618) with diabetes, congestive heart failure, or chronic obstructive pulmonary disease who received all their primary care from NPs in 2007. MAIN MEASURES Multivariable logistic regression model was used to assess patient and disease characteristics associated with switching from sole NP primary care in 2007 to receiving some or all primary care from physicians between 2008 and 2010. RESULTS Of elderly patients receiving all their primary care from NPs in 2007, 53.8% switched to receiving some or all primary care from physicians in 2008-2010. The switching patients had less comorbidity before the switch and were more likely to reside in metropolitan areas, ZIP code areas with high education or states with the most restriction on NP scope of practice. In multivariable analyses, significant predictors of switching included one of the following within 30 days before the switch: emergency room visits (odds ratio [OR] = 1.55, 95% confidence interval [CI] = 1.44-1.68), hospitalization (OR = 1.13, 95% CI = 1.02-1.25), new diagnosis of heart attacks (OR = 5.52, 95% CI = 4.33-7.02), pneumonia (OR = 4.84, 95% CI = 3.71-6.32), atrial fibrillation (OR = 3.99, 95% CI = 2.93-5.44), stroke (OR = 2.94, 95% CI = 2.31-3.74), or cancer (OR = 2.65, 95% CI = 1.94-3.63). CONCLUSIONS About half of Medicare patients under exclusive NP primary care switched to physicians for some or all primary care over a 3-year period. Future study is needed to understand the reasons for switching.
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Affiliation(s)
| | - Nai-Wei Chen
- The University of Texas Medical Branch, Galveston, TX, USA
| | - Mukaila Raji
- The University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- The University of Texas Medical Branch, Galveston, TX, USA
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Murphy M, Hollinghurst S, Salisbury C. Agreeing the content of a patient-reported outcome measure for primary care: a Delphi consensus study. Health Expect 2016; 20:335-348. [PMID: 27123987 PMCID: PMC5354062 DOI: 10.1111/hex.12462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND As the first contact for any health-related need, primary care clinicians often address multiple patient problems, with a range of possible outcomes. There is currently no patient-reported outcome measure (PROM) which covers this range of outcomes. Therefore, many research studies into primary care services use PROMs that do not capture the full impact of these services. OBJECTIVE The study aim was to identify outcomes sought by primary care patients which clinicians can influence, thus providing the basis for a new primary care PROM. METHODS We used a Delphi process starting with an outcomes list inductively derived in a prior qualitative study. Thirty-five experts were recruited into patient, clinician and academic panels. Participants rated each outcome on whether it was (i) relevant to health, (ii) influenced by primary care and (iii) detectable by patients. In each round, outcomes which passed/failed preset levels of agreement were accepted/rejected. Remaining outcomes continued to the next round. RESULTS The process resulted in a set of outcomes occupying the domains of health status, health empowerment (internal and external), and health perceptions. Twenty-six of 36 outcomes were accepted for inclusion in a PROM. Primary care having insufficient influence was the main reason for exclusion. CONCLUSIONS To our knowledge, this is the first time PROM outcomes have been agreed through criteria which explicitly exclude outcomes less relevant to health, uninfluenced by primary care or undetected by patients. The PROM in development covers a unique set of outcomes and offers an opportunity for enhanced research into primary care.
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Affiliation(s)
- Mairead Murphy
- Centre for Academic Primary Care, School for Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School for Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School for Social and Community Medicine, University of Bristol, Bristol, UK
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Contandriopoulos D, Brousselle A, Breton M, Sangster-Gormley E, Kilpatrick K, Dubois CA, Brault I, Perroux M. Nurse practitioners, canaries in the mine of primary care reform. Health Policy 2016; 120:682-9. [PMID: 27085958 DOI: 10.1016/j.healthpol.2016.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 01/13/2023]
Abstract
A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of "disruptive innovations" to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners' potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners' place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.
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Affiliation(s)
- Damien Contandriopoulos
- Faculté des sciences infirmières, Université de Montréal, Canada; Institut de recherche en santé publique de l'Université de Montréal, Canada.
| | - Astrid Brousselle
- Département des sciences de la santé communautaire, Université de Sherbrooke, Canada; Centre de recherche de l'hôpital Charles-LeMoyne, Canada.
| | - Mylaine Breton
- Département des sciences de la santé communautaire, Université de Sherbrooke, Canada; Centre de recherche de l'hôpital Charles-LeMoyne, Canada.
| | | | - Kelley Kilpatrick
- Faculté des sciences infirmières, Université de Montréal, Canada; Maisonneuve-Rosemont Hospital Research Centre, Canada.
| | - Carl-Ardy Dubois
- Faculté des sciences infirmières, Université de Montréal, Canada; Institut de recherche en santé publique de l'Université de Montréal, Canada.
| | - Isabelle Brault
- Faculté des sciences infirmières, Université de Montréal, Canada.
| | - Mélanie Perroux
- Faculté des sciences infirmières, Université de Montréal, Canada.
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Agarwal A, Zhang W, Kuo Y, Sharma G. Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician. PLoS One 2016; 11:e0148522. [PMID: 26910566 PMCID: PMC4765888 DOI: 10.1371/journal.pone.0148522] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/19/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To examine the process and outcomes of care of COPD patients by Advanced Practice Providers (APPs) and primary care physicians. METHODS We conducted a cross sectional retrospective cohort study of Medicare beneficiaries with COPD who had at least one hospitalization in 2010. We examined the process measures of receipt of spirometry evaluation, influenza and pneumococcal vaccine, use of COPD medications, and referral to a pulmonary specialist visit. Outcome measures were emergency department (ER) visit, number of hospitalizations and 30-day readmission in 2010. RESULTS A total of 7,257 Medicare beneficiaries with COPD were included. Of these, 1,999 and 5,258 received primary care from APPs and primary care physicians, respectively. Patients in the APP group were more likely to be white, younger, male, residing in non-metropolitan areas and have fewer comorbidities. In terms of process of care measures, APPs were more likely to prescribe short acting bronchodilators (adjusted odds ratio [aOR] = 1.18, 95%Confidence Interval [CI] 1.05-1.32), oxygen therapy (aOR = 1.25, 95% CI 1.12-1.40) and consult a pulmonary specialist (aOR = 1.39, 95% CI 1.23-1.56), but less likely to give influenza and pneumococcal vaccinations. Patients receiving care from APPs had lower rates of ER visits for COPD (aOR = 0.84, 95%CI 0.71-0.98) and had a higher follow-up rate with pulmonary specialist within 30 days of hospitalization for COPD (aOR = 1.25, 95%CI 1.07-1.48) than those cared for by physicians. CONCLUSIONS Compared to patients cared for by physicians, patients cared for by APPs were more likely to receive short acting bronchodilator, oxygen therapy and been referred to pulmonologist, however they had lower rates of vaccination probably due to lower age group. Patients cared for by APPs were less like to visit an ER for COPD compared to patients care for by physicians, conversely there was no differences in hospitalization or readmission for COPD between MDs and APPs.
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Affiliation(s)
- Amitesh Agarwal
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
| | - Wei Zhang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
| | - YongFang Kuo
- Office of Biostatistics, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
- Sealy Center of Aging, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
- Sealy Center of Aging, University of Texas Medical Branch (UTMB), Galveston, TX, United States of America
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Bentley M, Stirling C, Robinson A, Minstrell M. The nurse practitioner-client therapeutic encounter: an integrative review of interaction in aged and primary care settings. J Adv Nurs 2016; 72:1991-2002. [DOI: 10.1111/jan.12929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Bentley
- School of Health Sciences; University of Tasmania; Hobart Tasmania Australia
| | - Christine Stirling
- School of Health Sciences; University of Tasmania; Hobart Tasmania Australia
| | - Andrew Robinson
- Wicking Dementia Research and Education Centre; University of Tasmania; Hobart Tasmania Australia
| | - Melinda Minstrell
- Wicking Dementia Research and Education Centre; University of Tasmania; Hobart Tasmania Australia
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The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial. Int J Nurs Stud 2016; 58:12-20. [PMID: 27087294 PMCID: PMC4845697 DOI: 10.1016/j.ijnurstu.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
Background Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings. Objective To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition. Design Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years’ nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage. Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse. Settings 15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK. Participants 45 nurse practitioners and practice nurse trained in the use of clinical decision support software. Methods We investigated the associations between nursing characteristics and triage call disposition for patient ‘same-day’ appointment requests in general practice using multivariable logistic regression modelling. Results Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had ≥10 years’ experience with 24/35 (69%) having ≥20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more likely to recommend patients for follow-up (OR 3.17, 95% CI 1.18–5.55). Conclusion Nurse characteristics were associated with disposition of triage calls to within practice follow-up. Nurse practitioners or those who reported feeling ‘more prepared’ for the role were more likely to manage the call definitively. Practices considering nurse triage should ensure that nurses transitioning into new roles feel adequately prepared. While standardised training is necessary, it may not be sufficient to ensure successful implementation.
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Hyde A, Coughlan B, Naughton C, Hegarty J, Savage E, Grehan J, Kavanagh E, Moughty A, Drennan J. Nurses', physicians' and radiographers' perceptions of the safety of a nurse prescribing of ionising radiation initiative: A cross-sectional survey. Int J Nurs Stud 2016; 58:21-30. [PMID: 27087295 DOI: 10.1016/j.ijnurstu.2016.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND A new initiative was introduced in Ireland following legislative changes that allowed nurses with special training to prescribe ionising radiation (X-ray) for the first time. A small number of studies on nurse prescribing of ionising radiation in other contexts have found it to be broadly as safe as ionising radiation prescribing by physicians. Sociological literature on perceptions of safety indicates that these tend to be shaped by the ideological position of the professional rather than based on objective evidence. OBJECTIVES To describe, compare and analyse perceptions of the safety of a nurse prescribing of ionising radiation initiative across three occupational groups: nursing, radiography and medicine. DESIGN A cross-sectional survey design. SETTINGS Participants were drawn from a range of clinical settings in Ireland. PARTICIPANTS Respondents were 167 health professionals comprised of 49 nurses, 91 radiographers, and 27 physicians out of a total of 300 who were invited to participate. Non-probability sampling was employed and the survey was targeted specifically at health professionals with a specific interest in, or involvement with, the development of the nurse prescribing of ionising radiation initiative in Ireland. METHODS Comparisons of perspectives on the safety of nurse prescribing of ionising radiation across the three occupational groups captured by questionnaire were analysed using the Kruskal-Wallis H test. Pairwise post hoc tests were conducted using the Mann-Whitney U test. RESULTS While the majority of respondents from all three groups perceived nurse prescribing of ionising radiation to be safe, the extent to which this view was held varied. A higher proportion of nurses was found to display confidence in the safety of nurse prescribing of ionising radiation compared to physicians and radiographers with differences between nurses' perceptions and those of the other two groups being statistically significant. CONCLUSION That an occupational patterning emerged suggests that perceptions about safety and risk of nurse prescribing of ionising radiation are socially constructed according to the vantage point of the professional and may not reflect objective measures of safety. These findings need to be considered more broadly in the context of ideological barriers to expanding the role of nurses.
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Affiliation(s)
- Abbey Hyde
- UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland.
| | - Barbara Coughlan
- UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland.
| | - Corina Naughton
- Florence Nightingale School, King's College, James Clerk Maxwell Building, Waterloo, United Kingdom.
| | | | - Eileen Savage
- School of Nursing and Midwifery, University College Cork, Ireland.
| | - Jennifer Grehan
- UCD School of Medicine and Medical Science, University College Dublin, Ireland.
| | - Eoin Kavanagh
- UCD School of Medicine and Medical Science, University College Dublin, Ireland.
| | - Adrian Moughty
- Mater Misercordiae University Hospital, Dublin, Ireland.
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Perloff J, DesRoches CM, Buerhaus P. Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians. Health Serv Res 2015; 51:1407-23. [PMID: 26707840 DOI: 10.1111/1475-6773.12425] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). DATA SOURCE Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010. STUDY DESIGN Retrospective cohort design using propensity score weighted regression. DATA EXTRACTION METHODS Beneficiaries cared for by a random sample of NPs and primary care physicians. PRINCIPAL FINDINGS After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well. CONCLUSIONS This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.
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Affiliation(s)
| | | | - Peter Buerhaus
- College of Nursing, Montana State University, Bozeman, MT
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Anderson A, Roland M. Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study. BMJ Open 2015; 5:e009444. [PMID: 26614624 PMCID: PMC4663401 DOI: 10.1136/bmjopen-2015-009444] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the effect of using experienced general practitioners (GPs) to review the advice given by call handlers in NHS 111, a national service giving telephone advice to people seeking medical care. DESIGN Observational study following the introduction of GPs to review call handlers' decisions which had been made using decision support software. SETTING NHS 111 call centre covering Cambridgeshire and Peterborough. INTERVENTION When a call handler using standard NHS 111 decision support software would have advised the caller to attend the hospital accident and emergency (A&E) department, the decision was reviewed by an experienced GP. MAIN OUTCOME MEASURES Percentage of calls where an outcome other than A&E attendance was recommended by the GP. RESULTS Of 1474 cases reviewed, the GP recommended A&E attendance in 400 cases (27.1%). In the remainder of cases, the GP recommended attendance at a primary care out-of-hours centre or minor injury unit in 665 cases (45.2%) and self-management or some alternative strategy in 409 (27.8%). CONCLUSIONS Fewer callers to NHS 111 would be sent to emergency departments if the decision was reviewed by an experienced GP. Telephone triage services need to consider whether using relatively unskilled call handlers supported by computer software is the most cost-effective way to handle requests for medical care.
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Affiliation(s)
- Andrew Anderson
- Cambridgeshire and Peterborough Clinical Commissioning Group, Locton House, Cambridge, UK
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Campbell JL, Fletcher E, Britten N, Green C, Holt T, Lattimer V, Richards DA, Richards SH, Salisbury C, Taylor RS, Calitri R, Bowyer V, Chaplin K, Kandiyali R, Murdoch J, Price L, Roscoe J, Varley A, Warren FC. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess 2015; 19:1-212, vii-viii. [PMID: 25690266 DOI: 10.3310/hta19130] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice. OBJECTIVES In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice. DESIGN Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. SETTING General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). PARTICIPANTS Patients requesting same-day consultations. INTERVENTIONS Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation. MAIN OUTCOME MEASURES Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care. RESULTS Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it. CONCLUSIONS Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented. TRIAL REGISTRATION Current Controlled Trials ISRCTN20687662. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Emily Fletcher
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Nicky Britten
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Colin Green
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Tim Holt
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Valerie Lattimer
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - David A Richards
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rod S Taylor
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Raff Calitri
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Vicky Bowyer
- Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Katherine Chaplin
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Rebecca Kandiyali
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Jamie Murdoch
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Linnie Price
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Julia Roscoe
- Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anna Varley
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Fiona C Warren
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
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Potentially Preventable Hospitalizations in Medicare Patients With Diabetes: A Comparison of Primary Care Provided by Nurse Practitioners Versus Physicians. Med Care 2015; 53:776-83. [PMID: 26270826 DOI: 10.1097/mlr.0000000000000406] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few comparisons exist of the quality of primary care provided by nurse practitioners (NPs) versus physicians. METHODS Patients with a diagnosis of diabetes in 2007-2010 (n=345,819) who received all primary care from NPs or from generalist physicians in a given year were selected from a national sample of Medicare beneficiaries. We compared the rate of potentially preventable hospitalizations among patients who received primary care from NPs versus generalist physicians. Various statistical methods-including multivariable analysis, inverse probability weighting of propensity score, nonpooling propensity score adjustment and matching, and instrumental variable (IV) analysis-were used to control for differences in patient characteristics between the 2 groups. RESULTS Patients who received all of their primary care from NPs or from physicians differed by age, sex, race/ethnicity, socioeconomic status, residential area, and number of provider visits in the previous year. Nonpooling propensity score matching substantially reduced the differences, but neither IV approach satisfactorily reduced the differences. In multivariable analyses, receipt of primary care from an NP was associated with a decreased risk of hospitalization for potentially preventable conditions (OR: 0.90; 95% CI, 0.87-0.93). Similar results were found using conditional logistic regression models with propensity methods. We found smaller reductions in our analyses of "other hospitalizations" (OR: 0.96; 95% CI, 0.95-0.98). Both IV analyses showed associations between NP care and lower potentially preventable hospitalizations, but only 1 result was statistically significant. CONCLUSIONS Using potentially preventable hospitalizations as a quality indicator, primary care provided by NPs was at least comparable with that provided by generalist physicians.
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Abstract
Background Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. Aim This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs. Design and setting An observational study of 2086 patient records presenting at same-day appointments in 12 general practices in England. Method PA consultations were compared with those of GPs. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. Results There were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22, (US$ 10.15) lower (95% CI = −7.61 to −2.46, P<0.001). Conclusion The processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost. PAs offer a potentially acceptable and efficient addition to the general practice workforce.
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Fabrellas N, Juvé E, Solà M, Aurín E, Berlanga S, Galimany J, Berenguer L, Pujol MC, Lacuesta S, Villo MC, Torres M. A Program of Nurse Management for Unscheduled Consultations of Children With Acute Minor Illnesses in Primary Care. J Nurs Scholarsh 2015; 47:529-35. [PMID: 26473991 DOI: 10.1111/jnu.12169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Attention to patients with acute minor illnesses represents a major burden for primary care. Although programs of nurse care for children with acute minor illnesses in primary care started a long time ago, there is limited information about the results of these programs in current practice. OBJECTIVES The objective of this study was to assess the feasibility and efficacy of a program of nurse management for unscheduled consultations of children with acute minor illnesses. METHODS Observational study of children seeking unscheduled consultations for 16 acute minor illnesses in 284 primary care practices during a 2-year period. The program of nurse management used predefined management algorithms. FINDINGS Among 467,160 consultations performed, case resolution was achieved in 65.4%. The remaining 34.6% of cases were not solved by the primary healthcare nurse due to the existence of signs of alarm and were referred to a pediatrician. Return to consultation during a 7-day period for the same reason as the original consultation was only 2.6%. CONCLUSIONS A program that uses management algorithms is effective for nurse care management of children with acute minor illnesses in primary care. CLINICAL RELEVANCE Application of programs of nurse management for unscheduled consultations for children with acute minor illnesses is feasible and effective.
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Affiliation(s)
- Núria Fabrellas
- Professor of Nursing, School of Nursing, University of Barcelona, IDIBELL, Barcelona, Catalonia, Spain
| | - Eulàlia Juvé
- Nurse Coordinator, Institut Català de la Salut, Associate Professor of Nursing, School of Nursing, University of Barcelona, IDIBELL, Barcelona, Catalunya, Spain
| | - Montserrat Solà
- Professor of Nursing, School of Nursing, University of Barcelona, IDIBELL, Barcelona, Catalonia, Spain
| | - Eva Aurín
- Computer Scientist, Institut Català de la Salut, Barcelona, Catalunya, Spain
| | - Sofia Berlanga
- Pediatrics care nurse, Institut Català de la Salut, Associate Professor of Nursing, School of Nursing, University of Barcelona, Barcelona, Catalunya, Spain
| | - Jordi Galimany
- Professor of Nursing, School of Nursing, University of Barcelona, Barcelona, Catalonia, Spain
| | - Lidia Berenguer
- Pediatrics care nurse, SAP Girona, Institut Català de la Salut, Girona, Catalunya, Spain
| | - M Cèlia Pujol
- Pediatrics care nurse, SAP Alt Penedes, Institut Català de la Salut, Barcelona, Catalunya, Spain
| | - Sara Lacuesta
- Pediatrics care nurse, SAP Terres del Ebre, Institut Català de la Salut, Tarragona, Catalunya, Spain
| | - M Cinta Villo
- Pediatrics care nurse, SAP Terres del Ebre, Institut Català de la Salut, Tarragona, Catalunya, Spain
| | - Montserrat Torres
- Pediatrics care nurse, SAP Delta del Llobregat, Institut Català de la Salut, Barcelona, Catalunya, Spain
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74
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Kuo YF, Goodwin JS, Chen NW, Lwin KK, Baillargeon J, Raji MA. Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians. J Am Geriatr Soc 2015; 63:1980-8. [PMID: 26480967 PMCID: PMC4743647 DOI: 10.1111/jgs.13662] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners (NPs) with processes and cost of those cared for by primary care physicians (PCPs). DESIGN Retrospective cohort study. SETTING Primary care in communities. PARTICIPANTS Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354). MEASUREMENTS Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications (PIMs). RESULTS Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups (P = .56). CONCLUSION Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs.
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Affiliation(s)
- Yong-Fang Kuo
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - James S. Goodwin
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - Nai-Wei Chen
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Kyaw K. Lwin
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A. Raji
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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75
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Bank AJ, Gage RM. Annual impact of scribes on physician productivity and revenue in a cardiology clinic. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:489-95. [PMID: 26457055 PMCID: PMC4598196 DOI: 10.2147/ceor.s89329] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Scribes are increasingly being used in clinics to assist physicians with documentation during patient care. The annual effect of scribes in a real-world clinic on physician productivity and revenue has not been evaluated. Methods We performed a retrospective study comparing the productivity during routine clinic visits of ten cardiologists using scribes vs 15 cardiologists without scribes. We tracked patients per hour and patients per year seen per physician. Average direct revenue (clinic visit) and downstream revenue (cardiovascular revenue in the 2 months following a clinic visit) were measured in 486 patients and used to calculate annual revenue generated as a result of increased productivity. Results Physicians with scribes saw 955 new and 4,830 follow-up patients vs 1,318 new and 7,150 follow-up patients seen by physicians without scribes. Physicians with scribes saw 9.6% more patients per hour (2.50±0.27 vs 2.28±0.15, P<0.001). This improved productivity resulted in 84 additional new and 423 additional follow-up patients seen, 3,029 additional work relative value units (wRVUs) generated, and an increased cardiovascular revenue of $1,348,437. Physicians with scribes also generated an additional revenue of $24,257 by producing clinic notes that were coded at a higher level. Total additional revenue generated was $1,372,694 at a cost of $98,588 for the scribes. Conclusion Physician productivity in a cardiology clinic was ∼10% higher for physicians using scribes. This improved productivity resulted in 84 additional new and 423 additional follow-up patients seen in 1 year. The use of scribes resulted in the generation of 3,029 additional wRVUs and an additional annual revenue of $1,372,694 at a cost of $98,588.
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Affiliation(s)
- Alan J Bank
- United Heart and Vascular Clinic, St Paul, MN, USA
| | - Ryan M Gage
- United Heart and Vascular Clinic, St Paul, MN, USA
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76
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Cost-effectiveness of a physician-nurse supplementary triage assessment team at an academic tertiary care emergency department. CAN J EMERG MED 2015; 18:191-204. [PMID: 26337026 DOI: 10.1017/cem.2015.88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the cost-effectiveness of physician-nurse supplementary triage assistance team (MDRNSTAT) from a hospital and patient perspective. METHODS This was a cost-effectiveness evaluation of a cluster randomized control trial comparing the MDRNSTAT with nurse-only triage in the emergency department (ED) between the hours of 0800 and 1500. Cost was MDRNSTAT salary. Revenue was from Ontario's Pay-for-Results and patient volume-case mix payment programs. The incremental cost-effectiveness ratio was based on MDRNSTAT cost and three consequence assessments: 1) per additional patient-seen; 2) per physician initial assessment (PIA) hour saved; and 3) per ED length of stay (EDLOS) hour saved. Patient opportunity cost was determined. Patient satisfaction was quantified by a cost-benefit ratio. A sensitivity analysis extrapolating MDRNSTAT to different working hours, salary, and willingness-to-pay data was performed. RESULTS The added cost of the MDRNSTAT was $3,597.27 [$1,729.47 to ∞] per additional patient-seen, $75.37 [$67.99 to $105.30] per PIA hour saved, and $112.99 [$74.68 to $251.43] per EDLOS hour saved. From the hospital perspective, the cost-benefit ratio was 38.6 [19.0 to ∞] and net present value of -$447,996 [-$435,646 to -$459,900]. For patients, the cost-benefit ratio for satisfaction was 2.8 [2.3 to 4.6]. If MDRNSTAT performance were consistently implemented from noon to midnight, it would be more cost-effective. CONCLUSIONS The MDRNSTAT is not a cost-effective daytime strategy but appears to be more feasible during time periods with higher patient volume, such as late morning to evening.
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77
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Murphy M, Hollinghurst S, Turner K, Salisbury C. Patient and practitioners' views on the most important outcomes arising from primary care consultations: a qualitative study. BMC FAMILY PRACTICE 2015; 16:108. [PMID: 26297232 PMCID: PMC4546201 DOI: 10.1186/s12875-015-0323-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/13/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Primary care clinicians often address multiple patient problems, with a range of possible outcomes. There is currently no patient-reported outcome measure (PROM) which covers this range of outcomes. Consequently, many researchers use PROMs that do not capture the full impact of primary care services. In order to identify what outcomes a PROM for primary care would need to include, we conducted interviews with patients and practitioners. This paper reports these patient and practitioners' views on the outcomes arising from primary care consultations. METHODS Semi-structured interviews were held with 30 patients and eight clinicians across five sites in Bristol. Interviews were audio-recorded, transcribed and analysed thematically. We used a broad definition of health outcome as 'the impacts of healthcare on health, or a patient's ability to impact health' to identify outcomes through this process. RESULTS 10 outcome groups were identified. These occupied 3 domains: Health Empowerment: These are the internal and external resources which enable patients to improve their health. This involves 1) patients' understanding of their illnesses, 2) ability to self-care and stay healthy, 3) agreeing and adhering to a patient-clinician shared plan, 4) confidence in seeking healthcare and 5) access to support. Health Status: This involves 6) reduction of symptoms and 7) reducing the impact of symptoms on patients' lives. Health Perceptions: This involves 8) patients' satisfaction with their health, 9) health concerns, and 10) confidence in their future health. The structure, organisation and nature of primary care means it can affect all 3 domains. CONCLUSIONS No existing PROM captures all these outcomes. For example, many health empowerment PROMs do not consider patient preference on empowerment. Many health status tools are not responsive to changes resulting from primary care. Health perceptions PROMs have generally been designed for measuring personality traits rather than outcomes. This study provides a platform for designing a new PROM containing outcomes that matter to patients and can be influenced by primary care. Such a PROM would greatly enhance the value of primary care research.
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Affiliation(s)
- Mairead Murphy
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Katrina Turner
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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Klemenc-Ketis Z, Terbovc A, Gomiscek B, Kersnik J. Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study. J Clin Nurs 2015; 24:3077-83. [DOI: 10.1111/jocn.12889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Zalika Klemenc-Ketis
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
| | - Alenka Terbovc
- Zdravstveni dom Kranj; Osnovno zdravstvo Gorenjske; Kranj Slovenia
| | - Bostjan Gomiscek
- Faculty of Business; University of Wollongong in Dubai; Dubai UAE
- Faculty of Organizational Sciences; University of Maribor; Kranj Slovenia
| | - Janko Kersnik
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
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Swan M, Ferguson S, Chang A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health Care 2015; 27:396-404. [DOI: 10.1093/intqhc/mzv054] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2015] [Indexed: 12/11/2022] Open
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Sheaff R, Halliday J, Øvretveit J, Byng R, Exworthy M, Peckham S, Asthana S. Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03350] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAn ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.ObjectivesTo examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.MethodsMultiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.ResultsStarting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.ConclusionsOn balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | | | - John Øvretveit
- Medical Management Centre, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Richard Byng
- Health Services Management Centre, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Exworthy
- Centre for Health Services Studies, University of Birmingham, Birmingham, UK
| | - Stephen Peckham
- Department of Health Services Research and Policy, University of Kent, Kent, UK
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Martin-Misener R, Harbman P, Donald F, Reid K, Kilpatrick K, Carter N, Bryant-Lukosius D, Kaasalainen S, Marshall DA, Charbonneau-Smith R, DiCenso A. Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. BMJ Open 2015; 5:e007167. [PMID: 26056121 PMCID: PMC4466759 DOI: 10.1136/bmjopen-2014-007167] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. DESIGN A systematic review of randomised controlled trials reported since 1980. DATA SOURCES 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. INCLUDED STUDIES Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. RESULTS 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. CONCLUSIONS Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.
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Affiliation(s)
| | - Patricia Harbman
- Health Interventions Research Centre, Ryerson University, Toronto, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
| | - Kim Reid
- KJResearch, Rosemere, Quebec, Canada
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal, Hôpital Maisonneuve-Rosemont Research Centre, Montréal, Quebec, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Denise Bryant-Lukosius
- School of Nursing and Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | | | - Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Drummond AJ, Bingley M. Nurse practitioners in the emergency department: a discussion paper. CAN J EMERG MED 2015; 5:276-80. [PMID: 17472774 DOI: 10.1017/s1481803500008514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liddy C, Deri Armstrong C, McKellips F, Keely E. A comparison of referral patterns to a multispecialty eConsultation service between nurse practitioners and family physicians: The case for eConsult. J Am Assoc Nurse Pract 2015; 28:144-50. [PMID: 25965249 DOI: 10.1002/2327-6924.12266] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/15/2015] [Indexed: 11/06/2022]
Abstract
PURPOSE To explore referral patterns of nurse practitioners (NPs) and family physicians (FPs) using an electronic consultation (eConsult) service, and assess their perspectives on the service's value to their patients and themselves. DATA SOURCES A mixed methods study including a cross-sectional analysis of utilization data drawn from all eConsults completed from April 15, 2011 to September 30, 2014, and a content analysis of NP survey responses completed from January 1 to September 30, 2014. CONCLUSIONS A total of 4260 eConsults were included in the cross-sectional analysis (3686 from FPs and 574 from NPs). In our sample, NPs directed more cases to dermatology and fewer cases to cardiology and neurology (p < .0001) than did FPs, and were more likely to report that an eConsult led to new advice for a new or additional course of action (62.8% vs. 57.5%) and less likely to report it resulted in an avoided referral (35.5% vs. 41.8%, p = .005). NPs reported slightly higher levels of perceived value of eConsults for their patients and themselves. IMPLICATIONS FOR PRACTICE Differences in use and impact of eConsult exist between NPs and FPs. NPs value the service highly for their patients and themselves. The service reduces potential inequities related to outdated payment and scope of practice policies.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Fanny McKellips
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Erin Keely
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Martínez-González NA, Rosemann T, Djalali S, Huber-Geismann F, Tandjung R. Task-Shifting From Physicians to Nurses in Primary Care and its Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Med Care Res Rev 2015; 72:395-418. [PMID: 25972383 DOI: 10.1177/1077558715586297] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 04/10/2015] [Indexed: 11/17/2022]
Abstract
Task-shifting from physicians to nurses has gained increasing interest in health policy but little is known about its efficiency. This systematic review was conducted to compare resource utilization with task-shifting from physicians to nurses in primary care. Literature searches yielded 4,589 citations. Twenty studies comprising 13,171 participants met the inclusion criteria. Meta-analyses showed nurses had more return consultations and longer consultations than physicians but were similar in their use of referrals, prescriptions, or investigations. The evidence has limitations, but suggests that the effects may be influenced by the utilization of resources, context of care, available guidance, and supervision. Cost data suggest physician-nurse salary and physician's time spent on supervision and delegation are important components of nurse-led care costs. More rigorous research involving a wider range of nurses from many countries is needed reporting detailed accounts of nurses' roles and competencies, qualifications, training, resources, time available for consultations, and all-cause costs.
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Affiliation(s)
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Sima Djalali
- Institute of Primary Care, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Flore Huber-Geismann
- Institute of Primary Care, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
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Tsiachristas A, Wallenburg I, Bond CM, Elliot RF, Busse R, van Exel J, Rutten-van Mölken MP, de Bont A. Costs and effects of new professional roles: Evidence from a literature review. Health Policy 2015; 119:1176-87. [PMID: 25899880 DOI: 10.1016/j.healthpol.2015.04.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
Abstract
One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.
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Affiliation(s)
- A Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK.
| | - I Wallenburg
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C M Bond
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - R F Elliot
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - R Busse
- Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany
| | - J van Exel
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M P Rutten-van Mölken
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - A de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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86
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Lassi ZS, Cometto G, Huicho L, Bhutta ZA. Quality of care provided by mid-level health workers: systematic review and meta-analysis. Bull World Health Organ 2015; 91:824-833I. [PMID: 24347706 DOI: 10.2471/blt.13.118786] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/28/2013] [Accepted: 05/30/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of care provided by mid-level health workers. METHODS Experimental and observational studies comparing mid-level health workers and higher level health workers were identified by a systematic review of the scientific literature. The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria and data were analysed using Review Manager. FINDINGS Fifty-three studies, mostly from high-income countries and conducted at tertiary care facilities, were identified. In general, there was no difference between the effectiveness of care provided by mid-level health workers in the areas of maternal and child health and communicable and noncommunicable diseases and that provided by higher level health workers. However, the rates of episiotomy and analgesia use were significantly lower in women giving birth who received care from midwives alone than in those who received care from doctors working in teams with midwives, and women were significantly more satisfied with care from midwives. Overall, the quality of the evidence was low or very low. The search also identified six observational studies, all from Africa, that compared care from clinical officers, surgical technicians or non-physician clinicians with care from doctors. Outcomes were generally similar. CONCLUSION No difference between the effectiveness of care provided by mid-level health workers and that provided by higher level health workers was found. However, the quality of the evidence was low. There is a need for studies with a high methodological quality, particularly in Africa - the region with the greatest shortage of health workers.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University, PO Box 3500, Karachi 74550, Pakistan
| | - Giorgio Cometto
- Global Health Workforce Alliance Secretariat, World Health Organization, Geneva, Switzerland
| | - Luis Huicho
- Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University, PO Box 3500, Karachi 74550, Pakistan
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87
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Chattopadhyay A, Zangaro GA, White KM. Practice Patterns and Characteristics of Nurse Practitioners in the United States: Results From the 2012 National Sample Survey of Nurse Practitioners. J Nurse Pract 2015. [DOI: 10.1016/j.nurpra.2014.11.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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88
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Sun L, Jackson RA, Dunne H, Power VA. Impact of nurse practitioners in primary healthcare fee-for-service practice settings. Healthc Manage Forum 2015; 28:24-27. [PMID: 25838567 DOI: 10.1177/0840470414551904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The Nurse Practitioner (NP) role possesses a high value to Fee-For-Service (FFS) practices in the primary healthcare system. A case study evaluation of the NP roles in three FFS clinics showed positive impacts on patient satisfaction and physician experience. Physicians' FFS expenditures increased 12% after the NP implementation. Although NP services could provide cost savings to the acute care system, financial sustainability of the NP role in FFS practice remains a challenge.
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Affiliation(s)
- Lihong Sun
- Primary Healthcare, Chronic Disease Management & Rural Health Services, Island Health, Victoria, British Columbia, Canada.
| | - Rachel A Jackson
- Primary Healthcare, Chronic Disease Management & Rural Health Services, Island Health, Victoria, British Columbia, Canada
| | - Heather Dunne
- Primary Healthcare, Chronic Disease Management & Rural Health Services, Island Health, Victoria, British Columbia, Canada
| | - Victoria A Power
- Primary Healthcare, Chronic Disease Management & Rural Health Services, Island Health, Victoria, British Columbia, Canada
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89
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Gibb MA, Edwards HE, Gardner GE. Scoping study into wound management nurse practitioner models of practice. AUST HEALTH REV 2014; 39:220-227. [PMID: 25493448 DOI: 10.1071/ah14040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 10/06/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured. METHODS A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. RESULTS Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n=15). Most respondents (93%; n=14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60 min, with 32 min for follow ups. The most frequently performed activity was wound photography (83%; n=12), patient, family or carer education (75%; n=12), Doppler ankle-brachial pressure index assessment (58%; n=12), conservative sharp wound debridement (58%; n=12) and counselling (50%; n=12). The most routinely prescribed medications were local anaesthetics (25%; n=12) and oral antibiotics (25%; n=12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided. CONCLUSION This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured.
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Affiliation(s)
- Michelle A Gibb
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia
| | - Helen E Edwards
- Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. Email
| | - Glenn E Gardner
- Queensland University of Technology and Royal Brisbane and Women's Hospital, Level 3N Block, Kelvin Grove, Qld 4059, Australia. Email
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van Dillen SME, Hiddink GJ. To what extent do primary care practice nurses act as case managers lifestyle counselling regarding weight management? A systematic review. BMC FAMILY PRACTICE 2014; 15:197. [PMID: 25491594 PMCID: PMC4269898 DOI: 10.1186/s12875-014-0197-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/17/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND In this review study, we are the first to explore whether the practice nurse (PN) can act as case manager lifestyle counselling regarding weight management in primary care. METHODS Multiple electronic databases (MEDLINE, PsycINFO) were searched to identify relevant literature after 1995. Forty-five studies fulfilled the inclusion criteria. In addition, all studies were judged on ten quality criteria by two independent reviewers. RESULTS Especially in the last three years, many studies have been published. The majority of the studies were positive about PNs' actual role in primary care. However, several studies dealt with competency issues, including disagreement on respective roles. Thirteen studies were perceived as high quality. Only few studies had a representative sample. PNs' role in chronic disease management is spreading increasingly into lifestyle counselling. Although PNs have more time to provide lifestyle counselling than general practitioners (GPs), lack of time still remains a barrier. In some countries, PNs were rather ambiguous about their role, and they did not agree with GPs on this. CONCLUSION The PN can play the role of case manager lifestyle counselling regarding weight management in primary care in the UK, and wherever PNs are working under supervision of a GP and a primary health care team is already developed with agreement on roles. In countries in which a primary health care team is still in development and there is no agreement on respective roles, such as the USA, it is still the question whether the PN can play the case manager role.
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Affiliation(s)
- Sonja M E van Dillen
- Strategic Communication, Section Communication, Philosophy and Technology, Centre for Integrative Development (CPT-CID), Wageningen University, P.O. Box 8130, 6700 EW, Wageningen, the Netherlands.
| | - Gerrit J Hiddink
- Strategic Communication, Section Communication, Philosophy and Technology, Centre for Integrative Development (CPT-CID), Wageningen University, P.O. Box 8130, 6700 EW, Wageningen, the Netherlands.
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91
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Das BJ, Saikia BN, Baruah KK, Bora A, Bora M. Nutritional evaluation of fodder, its preference and crop raiding by wild Asian elephant (Elephas maximus) in Sonitpur District of Assam, India. Vet World 2014. [DOI: 10.14202/vetworld.2014.1082-1089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Campbell JL, Fletcher E, Britten N, Green C, Holt TA, Lattimer V, Richards DA, Richards SH, Salisbury C, Calitri R, Bowyer V, Chaplin K, Kandiyali R, Murdoch J, Roscoe J, Varley A, Warren FC, Taylor RS. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet 2014; 384:1859-1868. [PMID: 25098487 DOI: 10.1016/s0140-6736(14)61058-8] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the effectiveness and cost consequences of general practitioner-(GP)-led and nurse-led telephone triage compared with usual care for patients seeking same-day consultations in primary care. METHODS We did a pragmatic, cluster-randomised controlled trial and economic evaluation between March 1, 2011, and March 31, 2013, at 42 practices in four centres in the UK. Practices were randomly assigned (1:1:1), via a computer-generated randomisation sequence minimised for geographical location, practice deprivation, and practice list size, to either GP-led triage, nurse-led computer-supported triage, or usual care. We included patients who telephoned the practice seeking a same-day face-to-face consultation with a GP. Allocations were concealed from practices until after they had agreed to participate and a stochastic element was included within the minimisation algorithm to maintain concealment. Patients, clinicians, and researchers were not masked to allocation, but practice assignment was concealed from the trial statistician. The primary outcome was primary care workload (patient contacts, including those attending accident and emergency departments) in the 28 days after the first same-day request. Analyses were by intention to treat and per protocol. This trial was registered with the ISRCTN register, number ISRCTN20687662. FINDINGS We randomly assigned 42 practices to GP triage (n=13), nurse triage (n=15), or usual care (n=14), and 20,990 patients (n=6695 vs 7012 vs 7283) were randomly assigned, of whom 16,211 (77%) patients provided primary outcome data (n=5171 vs 5468 vs 5572). GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30-1·36), and nurse triage with a 48% increase (2·81 [SD 1·68]; RR 1·48, 95% CI 1·44-1·52). Eight patients died within 7 days of the index request: five in the GP-triage group, two in the nurse-triage group, and one in the usual-care group; however, these deaths were not associated with the trial group or procedures. Although triage interventions were associated with increased contacts, estimated costs over 28 days were similar between all three groups (roughly £75 per patient). INTERPRETATION Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered. FUNDING Health Technology Assessment Programme UK National Institute for Health Research.
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Affiliation(s)
- John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
| | - Emily Fletcher
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Nicky Britten
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Colin Green
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Tim A Holt
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Valerie Lattimer
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - David A Richards
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Raff Calitri
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Vicky Bowyer
- Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rebecca Kandiyali
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Jamie Murdoch
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Julia Roscoe
- Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anna Varley
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Fiona C Warren
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Rod S Taylor
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
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Lai MMY, Roberts N, Martin J. Effectiveness of patient feedback as an educational intervention to improve medical student consultation (PTA Feedback Study): study protocol for a randomized controlled trial. Trials 2014; 15:361. [PMID: 25227174 PMCID: PMC4176862 DOI: 10.1186/1745-6215-15-361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Oral feedback from clinical educators is the traditional teaching method for improving clinical consultation skills in medical students. New approaches are needed to enhance this teaching model. Multisource feedback is a commonly used assessment method for learning among practising clinicians, but this assessment has not been explored rigorously in medical student education. This study seeks to evaluate if additional feedback on patient satisfaction improves medical student performance. Methods The Patient Teaching Associate (PTA) Feedback Study is a single site randomized controlled, double-blinded trial with two parallel groups. An after-hours general practitioner clinic in Victoria, Australia, is adapted as a teaching clinic during the day. Medical students from two universities in their first clinical year participate in six simulated clinical consultations with ambulatory patient volunteers living with chronic illness. Eligible students will be randomized in equal proportions to receive patient satisfaction score feedback with the usual multisource feedback and the usual multisource feedback alone as control. Block randomization will be performed. We will assess patient satisfaction and consultation performance outcomes at baseline and after one semester and will compare any change in mean scores at the last session from that at baseline. We will model data using regression analysis to determine any differences between intervention and control groups. Full ethical approval has been obtained for the study. This trial will comply with CONSORT guidelines and we will disseminate data at conferences and in peer-reviewed journals. Discussion This is the first proposed trial to determine whether consumer feedback enhances the use of multisource feedback in medical student education, and to assess the value of multisource feedback in teaching and learning about the management of ambulatory patients living with chronic conditions. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613001055796.
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Affiliation(s)
- Michelle Mei Yee Lai
- Medical Student Programs, Eastern Health Clinical School, Monash University, Faculty of Medicine, Nursing and Health Science and Deakin University, School of Medicine, Level 3, 5 Arnold Street, Box Hill, Victoria 3128, Australia.
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Donald F, Kilpatrick K, Reid K, Carter N, Martin-Misener R, Bryant-Lukosius D, Harbman P, Kaasalainen S, Marshall DA, Charbonneau-Smith R, Donald EE, Lloyd M, Wickson-Griffiths A, Yost J, Baxter P, Sangster-Gormley E, Hubley P, Laflamme C, Campbell–Yeo M, Price S, Boyko J, DiCenso A. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract 2014; 2014:896587. [PMID: 25258683 PMCID: PMC4167459 DOI: 10.1155/2014/896587] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 12/25/2022] Open
Abstract
Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal and Research Centre of Hôpital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121, 5415 boulevard l'Assomption, Montréal, QC, Canada H1T 2M4
| | - Kim Reid
- KJ Research, Rosemere, QC, Canada J7A 4N8
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8
| | - Patricia Harbman
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Deborah A. Marshall
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6
| | | | - Erin E. Donald
- Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1
| | - Monique Lloyd
- International Affairs and Best Practice Guidelines Centre, Registered Nurses' Association of Ontario, 158 Pearl Street, Toronto, ON, Canada M5H 1L3
| | | | - Jennifer Yost
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Pamela Baxter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Esther Sangster-Gormley
- School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2
| | - Pamela Hubley
- The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue, Toronto, ON, Canada M5G 1X8
| | - Célyne Laflamme
- Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent, Suite 101, Ottawa, ON, Canada K1G 5Z3
| | - Marsha Campbell–Yeo
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Sheri Price
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Jennifer Boyko
- School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9
| | - Alba DiCenso
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
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Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook 2014; 63:144-53. [PMID: 25261383 DOI: 10.1016/j.outlook.2014.08.008] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/12/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Projections of physician shortages, an aging population, and insurance expansions have increased interest in expanding the number of primary care nurse practitioners (PCNPs) in the United States. Although information about the number and distribution of nurse practitioners is known, there is little information about the practice characteristics of PCNPs. The purpose of this study was to identify demographic and practice characteristics of PCNPs and compare these characteristics with primary care physicians (PCMDs). METHODS From November 23, 2011, to April 9, 2012, we conducted a national postal mail survey of 972 clinicians (467 PCNPs and 505 PCMDs). Questionnaire domains included compensation and billing practices; characteristics of patients treated; PCNPs' use of their own National Provider Identification number to bill services; how PCNPs spend their time; clinical and nonclinical activities performed; and whether PCNPs have privileges to admit, round on (i.e., oversee the care provided to) patients, and write orders independently of physicians. The response rate was 61.2%. DISCUSSION PCNPs are more likely than PCMDs to practice in urban and rural areas, provide care in a wider range of community settings, and treat Medicaid recipients and other vulnerable populations. Not only do most PCNPs work with PCMDs, but also the majority of both clinicians believe that increasing the supply of PCNPs will result in greater collaboration and team practice. Although PCNPs and PCMDs deliver similar services and spend their time in nearly identical ways, PCNPs work less hours and see fewer patients, and only a handful of PCNPs have their salary adjusted for productivity and quality performance. PCNPs cite government and local regulations as impeding their capacity to admit and round on patients in hospitals and long-term care facilities and write treatment orders without a physician cosignature. CONCLUSIONS Significant differences in demographic and practice characteristics exist between PCNPs and PCMDs. Whether working independently or with PCMDs, increasing the number of PCNPs can be expected to expand access to primary care, particularly for vulnerable populations, and for those gaining access to health insurance through the Affordable Care Act.
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Affiliation(s)
- Peter I Buerhaus
- Department of Health Policy, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN.
| | | | - Robert Dittus
- Institute for Medicine and Public Health, Nashville, TN; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
| | - Karen Donelan
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA
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Darvishpour A, Joolaee S, Cheraghi MA. A meta-synthesis study of literature review and systematic review published in nurse prescribing. Med J Islam Repub Iran 2014; 28:77. [PMID: 25405142 PMCID: PMC4219909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Prescribing represents a new aspect of practice for nurses. To make qualitative results more accessible to clinicians, researchers, and policy makers, individuals are urged to synthesize findings from related studies. Therefore this study aimed to aggregate and interpret existing literature review and systematic studies to obtain new insights on nurse prescription. METHODS This was a qualitative meta synthesis study using Walsh and Downe process. In order to obtain data all Digital National Library of Medicine's databases, search engines and several related sites were used. Full texts with "review and nurs* prescri* " words in the title or abstract in English language and published without any time limitation were considered. After eliminating duplicate and irrelevant studies, 11 texts were selected. Data analysis was conducted using qualitative content analysis. Multiple codes were compared based on the differences and similarities and divided to the categories and themes. RESULTS The results from the meta synthesis of the 11 studies revealed 8 themes namely: leading countries in prescribing, views, features, infrastructures, benefits, disadvantages, facilitators and barriers of nursing prescription that are discussed in this article. The results led to a schematic model. CONCLUSION Despite the positive view on nurse prescribing, there are still issues such as legal, administrative, weak research and educational deficiencies in academic preparation of nurses that needs more effort in these areas and requires further research.
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Affiliation(s)
- Azar Darvishpour
- 1. PhD Candidate, Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Iran University of Medical Science, Tehran, Iran & Social Determinants of Health (SDH) Research Center, School of Nursing and Midwifery, Guilan University of Medical Sciences (GUMS), Guilan, Iran.
| | - Soodabeh Joolaee
- 2. Associate Professor of Nursing, Center for Nursing Care Research, Department of Nursing Management, Faculty of Nursing and Midwifery, Iran University of Medical Science, Tehran, Iran.
| | - Mohammad Ali Cheraghi
- 3. Associate Professor, Department of critical Nursing, Faculty of Nursing and Midwifery, Tehran University of Medical Science, Tehran, Iran.
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Gielen SC, Dekker J, Francke AL, Mistiaen P, Kroezen M. The effects of nurse prescribing: A systematic review. Int J Nurs Stud 2014; 51:1048-61. [DOI: 10.1016/j.ijnurstu.2013.12.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 12/05/2013] [Accepted: 12/09/2013] [Indexed: 10/25/2022]
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Martínez-González NA, Djalali S, Tandjung R, Huber-Geismann F, Markun S, Wensing M, Rosemann T. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res 2014; 14:214. [PMID: 24884763 PMCID: PMC4065389 DOI: 10.1186/1472-6963-14-214] [Citation(s) in RCA: 186] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 03/10/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In many countries, substitution of physicians by nurses has become common due to the shortage of physicians and the need for high-quality, affordable care, especially for chronic and multi-morbid patients. We examined the evidence on the clinical effectiveness and care costs of physician-nurse substitution in primary care. METHODS We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected and critically appraised published randomised controlled trials (RCTs) that compared nurse-led care with care by primary care physicians on patient satisfaction, Quality of Life (QoL), hospital admission, mortality and costs of healthcare. We assessed the individual study risk of bias, calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD); and performed fixed-effects meta-analyses. RESULTS 24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies. CONCLUSIONS The available evidence continues to be limited by the quality of the research considered. Nurse-led care seems to have a positive effect on patient satisfaction, hospital admission and mortality. This important finding should be confirmed and the determinants of this effect should be assessed in further, larger and more methodically rigorous research.
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Affiliation(s)
| | - Sima Djalali
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Flore Huber-Geismann
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Stefan Markun
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
| | - Michel Wensing
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
- Scientific Institute for Quality in Healthcare, Radboud University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, Netherlands
| | - Thomas Rosemann
- Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland
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Drennan VM, Halter M, Brearley S, Carneiro W, Gabe J, Gage H, Grant R, Joly L, de Lusignan S. Investigating the contribution of physician assistants to primary care in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02160] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPrimary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.ObjectiveTo investigate the contribution of PAs to the delivery of patient care in primary care services in England.DesignA mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.ResultsThe rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.ConclusionsPAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Vari M Drennan
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Mary Halter
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Sally Brearley
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Wilfred Carneiro
- Directorate of Corporate Affairs, St George’s Healthcare NHS Trust, London, UK
| | - Jonathan Gabe
- Centre for Criminology and Sociology, Royal Holloway, University of London, London, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Robert Grant
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Louise Joly
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
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