Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial

Turnover Among Early Career Advanced Practice Providers in Urology

OBJECTIVE

To understand the patterns and predictors of practice movement among advanced practice providers (APPs). The role of APPs in urology has grown significantly, yet early career turnover is common and remains poorly understood.

MATERIALS AND METHODS

We conducted a retrospective cohort study using Medicare Data on Provider Practice and Specialty files between 2010 and 2021. We identified nurse practitioners and physician assistants who first billed Medicare Part B in urology practices. Time-to-event analysis was performed to examine the risk of practice movement, and Cox proportional hazards regression models identified factors associated with movement.

RESULTS

Of the 1003 APPs identified, 307 (30.6%) moved to a different practice, with a median time to movement of 14 months. Physician assistants were more likely to move compared to nurse practitioners, and APPs who moved were more often female and in practices with fewer physicians and other APPs. Most APPs who left urology transitioned to non-surgical specialties, with only 8.8% joining another urology practice.

CONCLUSION

Practice movement among APPs in urology is common in the early career and most APPs who leave urology practices go on to work in other specialties. Factors such as clinician type, gender, and practice size may influence practice movement. Our findings suggest that smaller practices may require improved strategies to retain APPs. Further work is needed to better understand reasons for this turnover and identify strategies for retention.

Scope of practice and opioid prescribing behavior of nurse practitioners serving Medicare beneficiaries

Policymakers aiming to increase access to health care while simultaneously keeping costs low and quality high are considering expanding the practice authority and prescriptive authority of nurse practitioners in order to address primary care shortages. While we know this increases access, some researchers argue that the expansion of job autonomy of nurse practitioners can compromise the quality and safety of rendered medical services. This paper investigates quality and safety outcomes in prescribing behaviors of nurse practitioners who have prescribed opioids for Medicare Part D beneficiaries using a unique source of policy variation, nurse practitioners with the ability to prescribe medication who move to either states with or without physician supervision. We find that scope of practice expansions do not compromise quality and safety in terms of potential abuse or misuse of prescriptive authority.

Advanced Practice Providers in Burn Care, 2013-2022

This study evaluated the prevalence and characteristics of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to burns in the United States from 2013 to 2022 using national claims data. Our analysis was a retrospective, large cohort study evaluating debridement, wound care, and office-based services provided by advanced practice providers from 2013 to 2022 using the Medicare Provider Utilization and Payment Data Public Use Files from the CMS. The reported provider type and billing codes were used to identify healthcare professionals providing burn care. Trends over the study period and available data about care provided were analyzed. From 2013 to 2022, burn care providers included 6918 (43.3%) surgeons, 4264 (26.7%) other physicians, and 4783 (30.0%) advanced practice providers. Overall, the number of advanced practice providers who billed for burn care increased by 250.4% from 714 in 2013 to 2502 in 2022. Compared with physicians, advanced practice providers were more likely to be female and provide care in micropolitan areas with less than 50,000 people. Based on these trends, we project that the number of advanced practice providers providing services related to burns will increase by 56.7% from 2502 in 2022 to 3921 (95% CI, 3541-4303; R2 = 0.97) in 2030. With a growing need for burn care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Effects of task-shifting from primary care physicians to nurses: an overview of systematic reviews

BACKGROUND

Task-shifting from primary care physicians (PCPs) to nurses is a means of overcoming PCP shortages and meeting the needs of patients receiving primary care. The aim of this overview of systematic reviews is to assess the effects of delegation or substitution of PCPs' activities by nurses on patient relevant, clinical, professional and health services-related outcomes.

METHODS

We conducted a systematic literature search for secondary literature in Medline, Embase, Pubmed, the Cochrane Library, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). We included systematic reviews and meta-analyses that analysed randomised controlled trials (RCTs) and controlled, prospective trials in English and German. Abstracts and full-text articles were screened independently by two reviewers. Full-text articles were assessed using the Overview Quality Assessment Questionnaire. After data extraction a narrative synthesis was performed. We defined patient-relevant outcomes as our primary outcomes.

RESULTS

We included six systematic reviews. The interventions included first contact, history taking and assessment, patient education, review of drug treatment, referrals to GPs and other health professionals, ordering further investigations and ongoing care. Two meta-analyses showed a relative risk reduction of mortality in favour of nurse-led care, whereby the reduction in one analysis was significant. The effect was highest in the group of more highly qualified nurse practitioners (RR 0.19), as opposed to nurse practitioners (RR 0.76) and registered nurses (RR 0.92). Two meta-analyses showed a relative risk reduction in hospital admissions and patient satisfaction. Whereas care conducted by physicians and registered nurses led to the same outcomes, care conducted by nurse practitioners led to better outcomes (RR 0.74). An analysis according to nursing group showed that patients were more satisfied with treatment by registered nurses (SMD 1.37) than with treatment conducted by nurse practitioners and more qualified nurse practitioners (SMD 0.17). In terms of patient-relevant outcomes, no differences were observed between physician-led care and nurse-led care in terms of physical function, quality of life and pain.

CONCLUSION

Nurse-led care is probably as safe or safer than physician-led care in terms of mortality and hospital admissions. However, the impact of nursing staff training has not been sufficiently examined.

A Citation Analysis of the Top 50 Most Cited Nurse Practitioner Publications

The role of nurse practitioners (NPs) has become integral to healthcare systems worldwide. Originating in the United States over 50 years ago, it has since been adopted by countries such as Canada, the United Kingdom, and Australia. To honor the research and contributions that have shaped the NP discipline, it is valuable to review and recognize key literature that has significantly impacted its development. Bibliometrics, a research methodology, offers an objective lens for evaluating the influence of scholarly articles on the evolution of a discipline. Citation analysis (CA), a key method in bibliometrics, examines how frequently a publication is cited by others, often serving as a measure of its impact, influence, and contribution to its field. This study aims to identify the top 50 most cited publications related to NPs in the Web of Science (WoS) database to review and describe the influential works that have contributed to the profession's growth. Comparisons are drawn with a parallel review in Scopus and recent NP-related bibliometric studies. In 2021, a structured search was conducted using the WoS Core Collection with key terms such as "Nurse Practitioner" and "Advanced Practice Nurse". Inclusion and exclusion criteria were applied, and publications were ranked by citation count from highest to lowest. The analysis covered citation counts, topics, publication dates/types, country of origin, author details (institution and discipline), and journal characteristics (e.g., impact factor, IF). The top 50 most cited articles and their characteristics are presented. Citation counts ranged from 78 to 656, with publication dates spanning six decades across 30 journals, 38 institutions, and 194 authors. The leading authors were Mary O'Neil Mundinger, Denise Bryant-Lukosius, and Alba DiCenso. Topics included the role's impact and development, registration/licensing, and scope of practice. Most articles (n = 35) were published in journals with an IF greater than 2. This review offers a systematic approach to identifying seminal works that have influenced the NP profession globally. While CA has its limitations, it provides a valuable method for literature review. This study contributes valuable insights into the history and development of NP research and offers guidance for future research efforts.

Nurse practitioners, physician assistants, and trust: A systematic review

BACKGROUND

The use of physician extenders (e.g., nurse practitioners [NPs] and physician assistants [PAs]) has risen in recent years in the U.S. health care domain, yet some scholars have questioned if physician extenders are being fully utilized in the health care field.

PURPOSES

The purpose of this research was to conduct a systematic review to determine if trust in the NP/PA might be influential in the ways these professionals are utilized. We view trust through the lens of Mayer et al. and their model of organizational trust, and we seek to examine how patients, physicians, and NPs/PAs themselves view one another.

METHODS

This systematic review spanned from 1996 to 2022 and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. The final sample consisted of 29 articles.

RESULTS

The findings point to how the antecedents of trust according to Mayer et al.; i.e., trustee's ability, benevolence, and integrity) influence the trusting relationships between patients and NPs/PAs and between physicians and NPs/PAs. Consequences and outcomes of trust are also discussed. Importantly, a trustor's propensity to trust and repeat interactions over time (e.g., feedback loop) is influential to trusting relationships.

PRACTICE IMPLICATIONS

These findings offer health care organizations insight into the mechanisms for building trust as physician extenders become more prominent in the health care field.

Evaluating the cost of NP-led vs. GP-led primary care in British Columbia

In 2020, British Columbia (BC) opened four pilot Nurse Practitioner Primary Care Clinics (NP-PCCs) to improve primary care access. The aim of this economic evaluation is to compare the average cost of care provided by Nurse Practitioners (NPs) working in BC's NP-PCCs to what it would have cost the government to have physicians provide equivalent care. Comparisons were made to both the Fee-For-Service (FFS) model and BC's new Longitudinal Family Physician (LFP) model. The analyses relied on administrative data, mostly from the Medical Services Plan (MSP) and Chronic Disease Registry (CDR) via BC's Health Data Platform. Results show the cost of NPs providing care in the NP-PCCs is slightly lower than what it would cost to provide similar care in medical clinics staffed by physicians paid through the LFP model. This suggests that the NP-PCC model is an efficient approach to increase accessibility to primary care services in BC and should be considered for expansion across the province.

Facilitators and barriers in implementing the nurse practitioner role in Japan: A cross-sectional descriptive study

AIM

To investigate the distribution of nurse practitioners (NPs) across Japan and their perceived facilitators and barriers to NP implementation in Japan.

BACKGROUND

NP certification examinations have been conducted in Japan since 2011, and by 2020, there were 487 NPs in the country. The momentum of NP implementation is slower in Japan compared with other countries.

METHODS

A cross-sectional descriptive study, following the STROBE guidelines, was conducted. Web-based survey questionnaires, developed by the authors, were administered to 248 NPs whose email addresses were maintained by the certification management body.

RESULTS

Valid responses were obtained from 101 NPs (response rate: 40.7%), of which 34% were male. The respondents had more than 12 years of registered nurse experience on an average before enrolling in the graduate NP program. 53% were employed as NPs from the beginning, while 25% were initially employed as registered nurses and later advanced to NPs, and 11% still worked as RNs. A majority worked in hospitals with beds. Many NPs perceived the lack of NP national licensure and reimbursement benefits as barriers to NP implementation, whereas recognition from superiors and organizations was considered facilitators.

CONCLUSIONS

Despite their small numbers in Japan, NPs take on crucial tasks and contribute to the appropriate distribution of medical resources. The NP licensure system and recognition from superiors and organizations may be necessary to promote NP roles in Japan.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Some certified NPs still work as registered nurses. Recognition from nursing and organization administrators is critical to implementing NPs. To this end, a reimbursement system benefiting the organizations and a legislation facilitating NP employment are required.

Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD

BACKGROUND

Early interventions in CKD have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain.

METHODS

In this propensity score-matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for ( 1 ) nurse practitioner care versus primary care alone and ( 2 ) nurse practitioner versus nephrologist care. Processes of care were measured within 1 year after cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score-matched groups.

RESULTS

A total of 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (82% versus 79%; absolute differences [ADs] 3.4% [95% confidence interval, 0.0% to 6.9%]) and statins (75% versus 66%; AD 9.7% [5.8% to 13.6%]), fewer prescriptions of nonsteroidal anti-inflammatory drugs (10% versus 17%; AD -7.2% [-10.4% to -4.2%]), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3; rate difference -9.2 [-14.7 to -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0; rate difference -2.7 [-3.6 to -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins, with no difference in the risks of experiencing adverse clinical outcomes.

CONCLUSIONS

Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone and similar to those with care by nephrologists.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_08_CJN0000000000000305.mp3.

Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians

BACKGROUND

Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care.

OBJECTIVE

To compare rates of inappropriate prescribing among NPs and primary care physicians.

DESIGN

Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state.

SETTING

29 states that had granted NPs prescriptive authority by 2019.

PATIENTS

Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019.

MEASUREMENTS

Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria.

RESULTS

Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states.

LIMITATION

The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings.

CONCLUSION

Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.

PRIMARY FUNDING SOURCE

The Robert Wood Johnson Foundation and National Science Foundation.

Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience

OBJECTIVE

This study aims to evaluate the impact of a primary care nurse practitioner (NP)-led clinic model piloted in British Columbia (Canada) on patients' health and care experience.

DESIGN

The study relies on a quasi-experimental longitudinal design based on a pre-and-post survey of patients receiving care in NP-led clinics. The prerostering survey (T0) was focused on patients' health status and care experiences preceding being rostered to the NP clinic. One year later, patients were asked to complete a similar survey (T1) focused on the care experiences with the NP clinic.

SETTING

To solve recurring problems related to poor primary care accessibility, British Columbia opened four pilot NP-led clinics in 2020. Each clinic has the equivalent of approximately six full-time NPs, four other clinicians plus support staff. Clinics are located in four cities ranging from urban to suburban.

PARTICIPANTS

Recruitment was conducted by the clinic's clerical staff or by their care provider. A total of 437 usable T0 surveys and 254 matched and usable T1 surveys were collected.

PRIMARY OUTCOME MEASURES

The survey instrument was focused on five core dimensions of patients' primary care experience (accessibility, continuity, comprehensiveness, responsiveness and outcomes of care) as well as on the SF-12 Short-form Health Survey.

RESULTS

Scores for all dimensions of patients' primary care experience increased significantly: accessibility (T0=5.9, T1=7.9, p<0.001), continuity (T0=5.5, T1=8.8, p<0.001), comprehensiveness (T0=5.6, T1=8.4, p<0.001), responsiveness (T0=7.2, T1=9.5, p<0.001), outcomes of care (T0=5.0, T1=8.3, p<0.001). SF-12 Physical health T-scores also rose significantly (T0=44.8, T1=47.6, p<0.001) but no changes we found in the mental health T scores (T0=45.8, T1=46.3 p=0.709).

CONCLUSIONS

Our results suggest that the NP-led primary care model studied here likely constitutes an effective approach to improve primary care accessibility and quality.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study

OBJECTIVE

To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.

DESIGN

Cross-sectional time series study.

SETTING

National data from the traditional Medicare insurance program in the USA.

PARTICIPANTS

Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.

MAIN OUTCOME MEASURES

The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.

RESULTS

From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).

CONCLUSION

The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Advancement of research on nurse practitioners: Setting a research agenda

BACKGROUND

Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them.

PURPOSE

We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce.

METHODS

Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions.

DISCUSSION

The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives.

CONCLUSION

The agenda can advance evidence on the NP workforce to guide policy and practice.

Nurse prescription start-up in a Spanish health organization: Nurses' preparedness and 6-month results

INTRODUCTION

Nurse prescribing is well consolidated in many countries. In Spain, recent legislation has allowed nurse to prescribe under specific conditions, but the implementation process is complex.

OBJECTIVES

First, to describe nurses' knowledge and expectations of nurse prescribing in a health institution in Spain. Second, to report the nurses' prescriptions in a pilot group at 6 months.

METHODS

A descriptive, online survey design was used to identify nurses' knowledge and expectations of prescribing. The results were compared according to the nurses' professional position and training. We analyzed the number and type of prescriptions issued in the first 6 months.

RESULTS

Training needs (overall score = 4.2/5) and lack of knowledge of the law (4.25/5) were scored lower by nurses with postgraduate training. Subjective assessment of preparedness among nurses was high (>4/5), and the highest-scoring expected impact was improvement in patients' experience (4.25/5). Years of nursing experience were negatively correlated with preparedness and the expectation of an increase in patient management errors. A total of 212 prescriptions were issued (2 drugs and 200 health devices).

CONCLUSIONS

Nurses perceived good preparedness but also the need for more training in medicines and prescribing law. Expectations of prescribing were favourable. Most prescriptions were for health devices.

Comparison Between Physicians' and Nurse Practitioners' Resource Utilization in the Diagnosis and Management of Bronchiolitis in the Pediatric Emergency Department

OBJECTIVE

This study aimed to describe the resource utilization of nurse practitioners (NPs) in the pediatric emergency department (ED) and compare among physicians.

METHODS

A retrospective cross-sectional study of secondary data analysis in a level 1 academic pediatric trauma center was conducted. Patients were aged 1 to 24 months, evaluated in the ED between January 1, 2014, and November 30, 2018, with a diagnosis of bronchiolitis or wheezing. Data included age group, length of stay, disposition, diagnostic tests (chest radiography [CXR], viral testing, respiratory syncytial virus test), treatment (bronchodilator, corticosteroid, antibiotic), and medical provider (physician, NP, combination of both). Resources were evaluated before (early era) and after (late era) the implementation of an institutional clinical practice guideline.Comparisons between groups were done through χ2, Fisher exact, or Kruskal-Wallis test, as appropriate.

RESULTS

A total of 5311 cases were treated by a physician (65.3%), an NP (30.3%), or a combination of both (4.3%). The was a difference in the use of CXR, respiratory syncytial virus testing, bronchodilators, and corticosteroids among providers (P = 0.001). In the late era, NPs were less likely to order a bronchodilator (odds ratio [OR], 0.390 [95% confidence interval, 0.318-0.478; P < 0.001]), whereas physicians were less likely to order a CXR (OR, 0.772 [0.667-0.894, P = 0.001]), bronchodilator (OR, 0.518 [0.449-0.596, P < 0.001]), or a corticosteroid (OR, 0.630 [0.531-0.749, P < 0.001]).

CONCLUSIONS

Nurse practitioners made fewer diagnostic and therapeutic orders. A clinical practice guideline on the diagnosis and management of children with bronchiolitis successfully decreased the use of nonrecommended tests and therapies among NP and physicians.

Engaging nurse practitioners and physician assistants to improve patient care and drive productivity in a radiology consult practice at a comprehensive cancer center

BACKGROUND

The demand for health care in the United States is increasing because of an aging population and an increase in the number of individuals insured. This has led to requests to revamp the primary care infrastructure fundamentally.

LOCAL PROBLEM

The optimal use of nurse practitioners (NPs) and physician assistants (PAs) is still a subject of debate, but recently, it was reported that for many medical conditions, NP and PA-managed care outcomes are consistent with physician-managed care outcomes.

METHODS

Radiologists' productivity was measured according to relative value units (RVUs)/shift and professional billing changes. Patient care metrics measured were prescribed protocol to patient appointment lead time and number of same-day prescribed imaging protocol changes.

INTERVENTIONS

The focus was on radiologists' productivity and patient care for three months before and three months after integrating NP and PA into our abdominal radiology consult service.

RESULTS

We observed significant increases in the mean RVUs/shift (15.2 ± 0.9 vs. 6.2 ± 1.8; p = .02), studies read per shift (10.1 ± 0.5 vs. 4.4 ± 1.5; p = .003), revenue per shift hour ($756.20 ± 55.40 vs. $335.40 ± 32.60; p = .007), and protocol prescription to patient appointment lead time (39.3 ± 6.7 days vs. 16.3 ± 2.9 days; p = .005) and saw significant decreases in the mean prescribed CT (19.3 ± 0.6 vs. 3.3 ± 0.6; p = .001) and MRI (11.7 ± 0.6 vs. 8.30 ± 0.12; p = .011) same day protocol changes in NP and PA integrated workflow.

CONCLUSIONS

These findings suggest that NP and PA can be effectively integrated into the abdominal radiology consult service, increasing radiologists' productivity and enhancing clinical care.

PAs and NPs improve patient care and productivity in a radiology consult practice

OBJECTIVE

To evaluate the effects on efficiency and patient care of the addition of physician assistants (PAs) and NPs to the abdominal radiology consult service.

METHODS

We obtained radiologist productivity and patient care metrics for 3 months before and 3 months after the integration of PAs and NPs into our consult service.

RESULTS

Integrating PAs and NPs into the workflow led to a significant increase in mean RVUs/shift (15.2 ± 0.9 versus 6.2 ± 1.8; P = .02), number of studies read per shift (10.1 ± 0.5 versus 4.4 ± 1.5; P = .003), revenue per shift hour ($756.20 ± $55.40 versus $335.40 ± $132.60; P = .007), protocol prescription to patient appointment lead time (39.3 ± 6.7 versus 16.3 ± 2.9 days; P = .005), and significant decreases in mean CT (19.3% ± 0.6 versus 3.3% ± 0.6; P = .001) and MRI (11.7% ± 0.6 versus 8.3% ± 0.12; P = .011) same-day protocol changes as patient appointments.

CONCLUSIONS

PAs and NPs can be effectively integrated into abdominal radiology consult service, increasing the productivity of radiologists, and enhancing clinical care.

NP Role and Patient Outcomes Are Supported by High-Level Evidence. Comment on Almutairi et al. Nurse Practitioner: Is It Time to Have a Role in Saudi Arabia? Nurs. Rep. 2020, 10, 41–47

This is a letter to the editor in response to the article titled “Nurse Practitioner: Is it Time to Have a Role in Saudi Arabia?” Clarifications on the nurse practitioner role definition and description, educational preparation, and quality and value of care are made and supported with authoritative, high-quality evidence.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis

OBJECTIVES

Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.

DESIGN, SETTING AND PARTICIPANTS

Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.

EXPOSURES

NPs/PAs.

MAIN OUTCOME MEASURES

Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.

RESULTS

Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination.

CONCLUSIONS AND RELEVANCE

While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

Advanced nursing practice and interprofessional dementia care (InDePendent): study protocol for a multi-center, cluster-randomized, controlled, interventional trial

BACKGROUND

A redistribution of tasks between specialized nurses and primary care physicians, i.e., models of advanced nursing practice, has the potential to improve the treatment and care of the growing number of people with dementia (PwD). Especially in rural areas with limited access to primary care physicians and specialists, these models might improve PwD's quality of life and well-being. However, such care models are not available in Germany in regular healthcare. This study examines the acceptance, safety, efficacy, and health economic efficiency of an advanced nursing practice model for PwD in the primary care setting in Germany.

METHODS

InDePendent is a two-arm, multi-center, cluster-randomized controlled intervention study. Inclusion criteria are age ≥70 years, cognitively impaired (DemTect ≤8) or formally diagnosed with dementia, and living in the own home. Patients will be recruited by general practitioners or specialists. Randomization is carried out at the physicians' level in a ratio of 1:2 (intervention vs. waiting-control group). After study inclusion, all participants will receive a baseline assessment and a follow-up assessment after 6 months. Patients of the intervention group will receive advanced dementia care management for 6 months, carried out by specialized nurses, who will conduct certain tasks, usually carried out by primary care physicians. This includes a standardized assessment of the patients' unmet needs, the generation and implementation of an individualized care plan to address the patients' needs in close coordination with the GP. PwD in the waiting-control group will receive routine care for 6 months and subsequently become part of the intervention group. The primary outcome is the number of unmet needs after 6 months measured by the Camberwell Assessment of Need for the Elderly (CANE). The primary analysis after 6 months is carried out using multilevel models and will be based on the intention-to-treat principle. Secondary outcomes are quality of life, caregiver burden, acceptance, and cost-effectiveness. In total, n=465 participants are needed to assess significant differences in the number of unmet needs between the intervention and control groups.

DISCUSSION

The study will provide evidence about the acceptance, efficacy, and cost-effectiveness of an innovative interprofessional concept based on advanced nursing care. Results will contribute to the implementation of such models in the German healthcare system. The goal is to improve the current treatment and care situation for PwD and their caregivers and to expand nursing roles.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04741932 . Registered on 2 February 2021.

Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans

Background

Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA.

Purpose

The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers.

Methods

We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]).

Results

Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99).

Conclusion

In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.

An examination of student nurse practitioners' diagnostic reasoning skills

AIM

To examine the diagnostic reasoning skills of two nurse practitioner student cohorts.

INTRODUCTION

Nurse practitioners continue to play a pivotal role in health care provision. Diagnostic reasoning is a core skill of advanced practice. A comparative diagnostic reasoning study between two student cohorts was undertaken between 2018 and 2019.

METHODS

A validated diagnostic reasoning scale was completed by nurse practitioner students in the United Kingdom and the United States of America at the beginning and end of their clinical placements. The study utilized descriptive quantitative statistics from the data submitted by 22 survey respondents from an online survey.

RESULTS

Analysis of the diagnostic reasoning skills suggested there was a difference in the structural memory scores when compared with the beginning of their clinical placements and the final semester of their clinical placements.

CONCLUSION

Diagnostic reasoning skills are a core skill of advanced practice. As students progress through their training, these skills improve. Despite the statistical difference in diagnostic reasoning scores, caution should be made in determining any larger implications due to the small number of participants in this study. Further study is needed in this area.

A policy analysis of nurse practitioner scope of practice in Massachusetts

ABSTRACT

Nurse practitioner (NP) practice has evolved since inception of the role in 1965. Educational requirements have been standardized requiring a master's degree, yet variation in NPs scope of practice exists across the United States. As the population ages and more Americans have health insurance coverage, the demand for health care continues to increase. Shortages of clinical providers and changes in hospital models of care continue to burden the health care system. Nurse practitioners have been found to provide safe, high-quality patient care and are a potential solution to ease the burden on our health care system. Nurse practitioner scope of practice restrictions limit the ability for NPs to practice independently. The purpose of this article was to analyze the advanced practice registered nurse's (APRNs) scope of practice policy in Massachusetts (MA) where APRNs just recently obtained full practice authority. Legislation to remove NP scope of practice restrictions in MA had been presented several times but was met with resistance from physician advocacy groups stating that NPs lack the education requirements to practice independently. A recent report from the MA Health Policy Commission demonstrates the impact that NPs have on lowering health care costs and servicing individuals in underserved areas of the state. During the pandemic, restrictions on NP scope of practice in MA were temporarily removed. It was realized that if NPs can practice independently during a pandemic, then they certainly are competent to practice independently at other times. A reassessment of NP scope of practice to allow for full authority should be completed nationally.

Attitudes toward risk among emergency physicians and advanced practice clinicians in Massachusetts

OBJECTIVE

Risk aversion is a personality trait influential to decision making in medicine. Little is known about how emergency department (ED) clinicians differ in their attitudes toward risk taking.

METHODS

We conducted a cross-sectional survey of practicing ED clinicians (physicians and advanced practice clinicians [APCs]) in Massachusetts using the following 4 existing validated scales: the Risk-Taking Scale (RTS), Stress from Uncertainty Scale (SUS), the Fear of Malpractice Scale (FMS), and the Need for (Cognitive) Closure Scale (NCC). We used Cronbach's α to assess the reliability of each scale and performed multivariable linear regressions to analyze the association between the score for each scale and clinician characteristics.

RESULTS

Of 1458 ED clinicians recruited for participation, 1116 (76.5%) responded from 93% of acute care hospitals in Massachusetts. Each of the 4 scales demonstrated high internal consistency reliability with Cronbach's αs ranging from 0.76 to 0.92. The 4 scales also were moderately correlated with one another (0.08 to 0.54; all P < 0.05). The multivariable results demonstrated differences between physicians and APCs, with physicians showing a greater tolerance for risk or uncertainty (NCC difference, -3.58 [95% confidence interval, CI, -5.26 to -1.90]; SUS difference, -3.14 [95% CI: -4.99 to -1.29]) and a higher concern about malpractice (FMS difference, 1.14 [95% CI, 0.11-2.17]). Differences were also observed based on clinician age (a proxy for years of experience), with greater age associated with greater tolerance of risk or uncertainty (age older than 50 years compared with age 35 years and younger; NCC difference, -2.84 [95% CI, -4.69 to -1.00]; SUS difference, -4.71 [95% CI, -6,74 to -2.68]) and less concern about malpractice (FMS difference, -3.19 [95% CI, -4.31 to -2.06]). There were no appreciable differences based on sex, and there were no consistent associations between scale scores and the practice and payment characteristics assessed.

CONCLUSION

We found that risk attitudes of ED clinicians were associated with type of training (physician vs APC) and age (experience). These differences suggest one possible explanation for the observed differences in decision making.

Midlevel Injectable Practice Patterns in Dermatology and Plastic Surgery Offices

BACKGROUND

There is limited knowledge on the extent physicians delegate cosmetic procedures to midlevel providers.

OBJECTIVE

To assess dermatology and plastic surgery practice patterns for the injections of neurotoxins and dermal fillers.

MATERIALS AND METHODS

Four hundred ninety-two dermatology and plastic surgery practices were identified from 10 major US metropolitan areas. These practices were contacted, and staff were asked a series of questions to best characterize the practice patterns in regard to who performs the injectables in the office.

RESULTS

Although most dermatology and plastic surgery practices had physicians as the only provider who gives injectables, 18.35% of dermatology and 25.4% of plastic surgery practices had nurse practioners and physician assistants giving injectables both with and without oversight of the supervising physician onsite.

CONCLUSION

In a large majority of both plastic surgery and dermatology practices, physicians exclusively perform injections of neurotoxins and fillers. For practices that allow midlevel providers to perform injectables, the level of physician supervision is variable. In a small percentage of plastic surgery practices, surveyed midlevel providers exclusively performed injectables.

The effect of team-based care practice on productivity for family physicians

ABSTRACT

About 60% of family physician practices employ PAs and/or NPs but gaps exist in the knowledge of the clinical effects on physician-PA and physician-NP teams. This review summarizes and comments on the significance of a recent report from the American Board of Family Medicine that compares the scope of practice of family physicians for family physicians practicing with either a PA, NP, or both.

Investigating the Use of Telemedicine for Digitally Mediated Delegation in Team-Based Primary Care: Mixed Methods Study

Background

Owing to the shortage of medical professionals, as well as demographic and structural challenges, new care models have emerged to find innovative solutions to counter medical undersupply. Team-based primary care using medical delegation appears to be a promising approach to address these challenges; however, it demands efficient communication structures and mechanisms to reinsure patients and caregivers receive a delegated, treatment-related task. Digital health care technologies hold the potential to render these novel processes effective and demand driven.

Objective

The goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use.

Methods

We conducted a combination of 19 individual and group interviews with 12 GPs and 14 MAs, seeking to identify relevant technologies for delegation purposes as well as stakeholders’ perceptions of their effectiveness. Furthermore, a web-based survey was conducted asking the interviewees to order identified technologies based on their assessed applicability in multi-actor patient care. Interview data were analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize the survey data, leading to a triangulation of the results.

Results

Our results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed to improve the development and distribution of innovative technologies and to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultations, portable electrocardiograms, or telemedical stethoscopes, can counteract current challenges in primary care because of its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes.

Conclusions

Technology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance of such innovative approaches increases with the tremendous need for differentiated and effective care, such as during the ongoing COVID-19 pandemic. For the successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role as mediators between GPs and patients, MAs are potentially able to counteract patients’ resistance toward using innovative technology and compensate for patients’ limited access to technology and care facilities.

Health care costs associated with primary care physicians versus nurse practitioners and physician assistants

BACKGROUND

Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving.

PURPOSE

This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians).

METHODS

A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs.

RESULTS

The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively.

IMPLICATIONS FOR PRACTICE

This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area.

Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care

OBJECTIVE

This study sought to assess whether patients with autoimmune disease would accept advanced practice providers (APPs) as an option to fill the growing shortage of rheumatologists.

METHODS

We administered a cross-sectional survey to 500 patients or parents of children who reported having been diagnosed with qualifying autoimmune conditions and who had seen their primary rheumatology providers in the past 6 months. Respondents self-reported whether their primary providers were rheumatologists or APPs. Our analysis compared the attitude and experience of the patients whose primary rheumatology providers were APPs with those of patients whose primary providers were rheumatologists.

RESULTS

Of respondents, 36.8% reported having APPs as primary rheumatology providers. Patients of APPs were significantly more likely to arrive at their provider's office in 15 minutes or less (p < 0.01) and to be able to schedule routine and urgent appointments sooner (p = 0.02, 0.05). There were no significant differences for overall patient experience of care between provider types. Most patients rated their providers highly, but those who saw rheumatologists rated their providers significantly higher (p < 0.01). APP patients were significantly more likely than rheumatologist patients to prefer to see APPs over rheumatologists (p < 0.01) and to recommend APPs (p < 0.01).

CONCLUSIONS

APPs may improve access to care, and regardless of provider type, patients rated their overall experience of care similarly. Overall, patient attitudes toward APPs were positive regardless of provider type, although APP patients held more positive overall attitudes toward APPs than did rheumatologist patients.

'She taught me': factors consumers find important in nurse practitioner and pharmacist prescriber services

BACKGROUND

Advanced practitioner services, such as those nurse practitioners and pharmacist prescribers provide, are an opportunity to improve health care delivery. In New Zealand, these practitioners remain underutilised, despite research suggesting they offer safe and effective care, and considerable international literature recording patient satisfaction with these roles. This study aimed to explore factors underlying consumer satisfaction with primary health care nurse practitioner and pharmacist prescriber services.

METHODS

As part of a larger realist evaluation, 21 individuals receiving advanced practitioner services participated in semi-structured interviews. These interviews were transcribed and coded against context-mechanism-outcome configurations tested and refined throughout the research.

RESULTS

Study findings emphasise the importance of consumer confidence in the provider as a mechanism for establishing advanced practitioner roles. Underlying this confidence is a recognition that these practitioners work in a more accessible manner, engage at the individual's 'level', and operate with passion.

CONCLUSIONS

This research offers learnings to re-engineer service delivery within primary health care to make best use of the entire health care team by including consumers in the design and introduction of new roles.

Enablers, Barriers, and Contributions of Pediatric Nurse Practitioners to Ambulatory Specialty Care

INTRODUCTION

The objective of this study was to explore the enablers of and barriers to the contribution of nurse practitioners (NPs) in pediatric specialty care.

METHOD

A total of 11 NPs in pediatric medical specialties were interviewed regarding teamwork, communication, documentation, satisfaction, overall role, and perception of the value they contribute to care.

RESULTS

Themes were identified related to structural and organizational enablers and barriers that facilitate or hinder the NPs' contribution to pediatric specialty care.

DISCUSSION

The findings of this study can provide a better understanding of the role of NPs caring for pediatric patients in the specialty setting and can also help guide organizational environments to maximize the potential of pediatric NPs to positively affect patient care.

Methodology for a six-state survey of primary care nurse practitioners

BACKGROUND

Primary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations.

PURPOSE

In this paper, we report the methods of the largest survey of primary care NPs to date.

METHODS

To overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments.

FINDINGS

While we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty.

DISCUSSION

In future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.

Attitudes towards advanced nursing roles in primary dementia care - Results of an observational study in Germany

AIMS

To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care.

DESIGN

Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017-August 2018.

METHODS

A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test.

RESULTS

Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia-specific qualification was rated as best suitable for advanced nursing roles, followed by 'no specific qualification' if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses.

CONCLUSION

There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks.

IMPACT

Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.

The Impact of Level of Physical Therapist Assistant Involvement on Patient Outcomes Following Stroke

OBJECTIVE

This study investigates if higher utilization of physical therapist assistants adversely affects patient outcomes in the acute rehabilitation setting for patients following a cerebrovascular accident (CVA).

METHODS

Participants were admitted to 1 of 5 inpatient rehabilitation facilities following a CVA from 2008 to 2010. High physical therapist assistant use was defined as ≥20% of the physical therapist visits being provided by the physical therapist assistant for an episode of care. Multivariable regression techniques examined differences in functional outcome, discharge location, and length of stay between high and low physical therapist assistant use groups. Propensity scoring methods supplemented findings of the regression analyses.

RESULTS

Of the 1561 participants, 496 (32%) had high physical therapist assistant involvement. Baseline participant characteristics such as age, sex, baseline motor function, and comorbidities did not differ between high and low physical therapist assistant use groups. After adjusting for patient characteristics, rehabilitation facility, and year, higher physical therapist assistant use did not adversely affect functional outcome or length of stay. Fewer conclusions can be drawn regarding discharge location, although there was no significant difference in discharge location between groups with high and low physical therapist assistant utilization. Propensity scoring methods supported the findings of the regression analyses.

CONCLUSIONS

Higher physical therapist assistant involvement in the rehabilitation of patients following CVA did not adversely affect functional outcome, increase length of stay, or reduce the likelihood of discharge to home from an inpatient rehabilitation facility.

IMPACT

The results demonstrate the value of the physical therapist assistant in the provision of physical therapy for patients with stroke in the inpatient rehabilitation setting. Higher involvement of the physical therapist assistant may provide cost savings while maintaining patient outcomes for this setting and population.

Use of a State Registry to Compare Practices of Physicians and Nurse Practitioners in Completing Physician Orders for Life-Sustaining Treatment Forms

Background: Understanding the role of nonphysicians in Physician Orders for Life-Sustaining Treatment (POLST) completion is limited. Objectives: To examine the role that nurse practitioners (NPs) play in POLST completion and differences between NPs and physicians in POLST orders. Design: Retrospective observational study. Setting/Subjects: A total of 3829 POLST forms submitted to the West Virginia (WV) e-Directive Registry between July 1, 2018 and June 30, 2019, which was completed by 98 NPs and 511 physicians. Measurements: POLST forms completed and orders in POLST Section A and Section B by all physicians and NPs according to practice (primary care, palliative care, hospital, and nursing home) and by palliative care physicians and NPs only. Results: NPs completed almost twice as many forms on average as physicians (9.54 ± 20.82 vs. 5.66 ± 17.18, p = 0.0064). NPs constituted 16.10% (98/609) of the clinicians writing POLST forms but completed 24.40% (935/3829) of the forms (p < 0.001). Compared with physicians' orders, a greater percentage of NP's orders was for do-not-resuscitate in Section A (87.20% vs. 72.60%, p < 0.001) and comfort measures in Section B (42.90% vs. 33.10%, p < 0.001). There was a greater percentage of NPs in palliative care practice than physicians (23.50% vs. 6.07%, p < 0.001), and palliative care NPs completed 64.20% (600/935) of the forms submitted by NPs compared with palliative care physicians who completed 17.90% (517/2894) of the forms submitted by physicians (p < 0.001). Conclusions: In WV, physician and NP POLST completion differs based on practice. NPs completed significantly more POLST forms on average and more often ordered comfort measures. NPs can play a significant role in POLST completion.

Regional Variations in Maternal Mortality and Health Workforce Availability in the United States

BACKGROUND

Skilled, high-quality health providers and birth attendants are important for reducing maternal mortality.

OBJECTIVE

To assess whether U.S. regional variations in maternal mortality rates relate to health workforce availability.

DESIGN

Comparison of regional variations in maternal mortality rates and women's health provider rates per population and identification of a relationship between these measures.

SETTING

U.S. health system.

PARTICIPANTS

Women of child-bearing age and women's health providers, as captured in federal data sources from the Centers for Disease Control and Prevention, Census Bureau, and Health Resources and Services Administration.

MEASUREMENTS

Regional-to-national rate ratios for maternal mortality and women's health provider availability, calculated per population for women of reproductive age. Provider availability was examined across occupations (obstetrician-gynecologists, internal medicine physicians, family medicine physicians, certified nurse-midwives), in service-based categories (birth-attending and primary care providers), and across the entire women's health workforce (all studied occupations).

RESULTS

Maternal deaths per population increased nationally from 2009 to 2017 and, in 2017, were significantly higher in the South and lower in the Northeast (P < 0.001) than nationally. The occupational composition and per-population availability patterns of the women's health workforce varied regionally in 2017. The South had the lowest availability in the nation for nearly every health occupation and category studied, and the Northeast had the highest. This exploratory analysis suggests that subnational levels of provider availability across a region may be associated with higher maternal mortality rates.

LIMITATIONS

No causal relationship was established. Nationally representative maternal mortality and health workforce data sources have well-known limitations. Low numbers of observations limit statistical analyses.

CONCLUSION

Regional variations in maternal mortality rates may relate to the availability of birth-attending and primary care providers.

PRIMARY FUNDING SOURCE

None.

Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels (P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team (P = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Role of Nurse Practitioners in Caring for Patients With Complex Health Needs

OBJECTIVE

The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics.

DESIGN

An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics.

KEY RESULTS

In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%).

CONCLUSIONS

Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.