Characteristics of nurse practitioners and physician assistants in the United States

Mentorship effect for PAs at an academic medical center and its healthcare system

PURPOSE

Mentorship has many notable benefits. Research about mentorship for physician associates/assistants (PAs) is limited. This study sought to uncover more detailed information on mentorship and its effect on PAs.

METHODS

A survey was sent via email to all PAs and advanced practice registered nurses at our institution. Subgroup analysis was performed on PA respondents, including satisfaction and independent predictors associated with mentorship.

RESULTS

Of the 295 PAs, 63 (21.4%) identified having a mentor. Those with a mentor were statistically more likely to function as a mentor (OR 2.7 [95% CI 1.5-4.9], P = .001), have an academic rank of assistant professor or higher (OR 2.7 [95% CI 1.3-5.5], P = .007), be under age 45 years (OR 6.1 [95% CI 2.1-17.4], P = .008), be less than 10 years into their career (OR 3.1 [95% CI 1.7-5.7], P = .002), and be satisfied with mentorship (88.9% versus 23.9%, P < .001).

CONCLUSIONS

Mentorship for PAs is crucial and can boost academic promotion and career satisfaction.

Closing the Opioid Treatment Gap Through Advance Practice Nursing Activation: Curricular Design and Initial Outcomes

INTRODUCTION

Buprenorphine, an effective medication for opioid use disorder (MOUD), reduces opioid-related harms including overdose, but a significant gap exists between MOUD need and treatment, especially for marginalized populations. Historically, low MOUD treatment capacity is rising, driven by advanced practice registered nurses (APRNs). A graduate nursing course was designed to increase equitable buprenorphine treatment delivery by APRNs. We report on baseline findings of a curriculum evaluation study with a pretest-posttest design.

DESIGN

Computerized surveys assessed trainee satisfaction with the course, trainee knowledge for providing MOUD, and trainee satisfaction in working with people who use drugs.

METHODS

Quantitative survey results utilizing Likert scales are presented.

RESULTS

Baseline precourse surveys revealed less than half (44%) of APRN students agreed/strongly agreed that they had a working knowledge of drugs and drug-related problems and 37% agreed/strongly agreed that they knew enough about the causes of drug problems to carry out their roles when working with people who use drugs. Approximately two thirds of APRN students agreed/strongly agreed that they want to work with people who use drugs (63%), that it is satisfying to work with people who use drugs (66%), and that it is rewarding to work with people who use drugs (63%). Nearly all students reported high satisfaction with the course.

CONCLUSION

APRN students reported high satisfaction with a novel course grounded in health equity that has potential to reduce health disparities and accelerate the closure of the MOUD treatment gap, particularly for racial/ethnic minorities, rural populations, and transition-age youth.

Examining the perceived impact of the COVID-19 pandemic on cervical cancer screening practices among clinicians practicing in Federally Qualified Health Centers: A mixed methods study

Background

The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed methods study we explored perceived pandemic-related practice changes to cervical cancer screenings in federally qualified health centers (FQHCs).

Methods

Between October 2021 and June 2022, we conducted a national web survey of clinicians (physicians and advanced practice providers) who performed cervical cancer screening in FQHCs in the United States during the post-acute phase of the COVID-19 pandemic, along with a sub-set of qualitative interviews via video conference, to examine perceived changes in cervical cancer screening practices during the pandemic.

Results

A total of 148 clinicians completed surveys; a subset (n=13) completed qualitative interviews. Most (86%) reported reduced cervical cancer screening early in the pandemic, and 28% reported continued reduction in services at the time of survey completion (October 2021- July 2022). Nearly half (45%) reported staff shortages impacting their ability to screen or track patients. Compared to clinicians in Obstetrics/Gynecology/Women's health, those in family medicine and other specialties more often reported reduced screening compared to pre-pandemic. Most (92%) felt that screening using HPV self-sampling would be very or somewhat helpful to address screening backlogs. Qualitative interviews highlighted the impacts of staff shortages and strategies for improvement.

Conclusions

Findings highlight that in late 2021 and early 2022, many clinicians in FQHCs reported reduced cervical cancer screening and of pandemic-related staffing shortages impacting screening and follow-up. If not addressed, reduced screenings among underserved populations could worsen cervical cancer disparities in the future.

Funding

This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.

The current state of transplant advanced practice providers: results of the advanced practice provider practice survey

Advanced practice providers (APPs) are trained, licensed health care providers. The American Society of Transplant APP community of practice developed an electronic survey to investigate transplant APP demographics, scope of practice, and academic activities. We defined the top of scope of practice as delivering health care to the fullest extent of APP education and training as allowed by state laws and regulations. From July 11, 2020, to August 31, 2020, 307 invitations were e-mailed and survey links were distributed electronically on the community of practice hub and social media. Two hundred fifty-three APPs responded. APPs practice in inpatient and outpatient settings. Among the respondent APPs, 11.5% assist in the operating room (OR), 46.3% of inpatient and 46.6% of outpatient APPs perform procedures, and 17.8% run specialized APP clinics. 26.2% feel they do not function at the top of their scope of practice and 29.7% were expected to function as a coordinator some or all of the time. Forty-three percent gave invited lectures, 41.5% have published, and 69.2% teach physician trainees. 74.7% and 35.1%, respectively, would like to participate in research and teach but are limited by time, opportunity, and experience. APPs should practice at the top of their scope of practice. Clinical workloads and lack of time limit the ability of APP to teach and contribute to evidence-based practice.

Impact of Advanced Practice Provider Integration into Multispecialty Group Practices on Outcomes Following Major Surgery

Background. While advanced practice providers (APPs) are increasingly integrated into care delivery models, little is known about their impact in surgical settings. Given that many patients undergo surgery in multispecialty group practice settings, we examined the impact of APP integration into such practices on outcomes after major surgery. Methods. We used a 20% sample of national Medicare claims to identify 190 101 patients who underwent 1 of 4 major surgeries (coronary artery bypass graft [CABG], colectomy, major joint replacement, and cystectomy) at multispecialty group practices from 2010 through 2016. The level of APP integration was measured as the ratio of APPs to physicians within each practice. Rates of mortality, major complications, and readmission within 30 days of discharge after the index surgery were compared between patients treated in practices with low, medium, and high levels of APP integration using multivariable regression analysis. Results. Relative to patients treated in practices with low APP integration, those treated in practices with medium or high APP integration had significantly lower rates of mortality (2.4% [low integration] vs 1.9% [medium integration] vs 2.0% [high integration]; P < .01), major complications (34.1% [low] vs 31.2% [medium] vs 30.2% [high]; P < .01), and readmission (11.7% [low] vs 10.6% [medium] vs 10.1% [high]; P < .01). This relationship was consistent for virtually all outcomes when considering each surgery type individually. Conclusions. Integration of APPs into multispecialty group practices was associated with improved postoperative outcomes after major surgery. Future research should identify the mechanisms by which APPs improve outcomes to inform optimal utilization.

Defining the role of advanced care practitioners in pediatric surgery practice

INTRODUCTION

The role of advanced care practitioners (ACPs) in pediatric surgery is increasingly important and not well described.

METHODS

Electronic surveys were sent to pediatric surgery division chiefs within the Children's Hospital Association.

RESULTS

We received 77/163 survey responses (47%). The median number of ACPs per service was 3.0 (range 0-35). ACP number correlated with inpatient census, surgeon number, case volume, trauma centers, intensive care unit status, and fellowship programs but not with presence of residents/hospitalists, hospital setting, or practice type. Nearly all programs incorporated nurse practitioners while almost half utilized physician assistants. Approximately one-third of ACPs were designated for subspecialties (35%) such as trauma and colorectal. Only 9% of centers had surgeon-specific ACPs. ACP responsibilities included both inpatient and outpatient tasks. Nearly all ACPs participated in procedures (89%), mostly bedside (80%). All ACPs worked daytime shifts, with less nights and weekends. Most ACPs billed for services (80%). Satisfaction with ACP coverage was widespread and did not correlate with ACP number. Most respondents felt that ACPs enhance, and not hinder, resident/fellow training (85%).

CONCLUSION

ACPs are useful adjuncts in pediatric surgery. A better understanding of practice patterns may help optimize utilization to enhance patient care and can be used to advocate for appropriate resources.

Primary care workforce paradox: A physician shortage and a PA and NP surplus

OBJECTIVE

Primary care workforce projections continue to predict significant physician shortages. An oversupply of primary care physician assistants (PAs) and NPs also is predicted. This paradox calls into question the assumptions that underlie workforce projection models, which likely underestimate the primary care contributions of PAs and NPs.

METHODS

Federally qualified health center data from the 2016-2019 Uniform Data System were used to calculate the number of clinic visits per full-time equivalent (FTE) physician, PA, and NP. Visits per FTE were compared across provider type to determine provider-specific productivity ratios.

RESULTS

The combined PA and NP productivity ratio increased relative to physicians in each year, ranging from 0.85 in 2016 to 0.88 in 2019. Clinic visits per FTE for PAs and family physicians were nearly equivalent.

CONCLUSIONS

Primary care workforce projection models should be reexamined to more accurately capture the productivity of PAs and NPs.

The impact of nurse practitioner and physician assistant workforce supply on Medicaid-related emergency department visits and hospitalizations

BACKGROUND

New York State (NYS) has approximately 4.7 million Medicaid beneficiaries with 75% having at least one or more chronic conditions. An estimated 10% of Medicaid beneficiaries seek emergency department (ED) services for nonurgent matters. It is unclear if an increased supply of nurse practitioners (NPs) and physician assistants (PAs) impact utilization of ED and subsequent hospitalizations for chronic conditions.

PURPOSE

To investigate the relationship between NYS workforce supply (physicians, NPs, and PAs) and 1) ED use and 2) in-patient hospitalizations for chronically ill Medicaid beneficiaries.

METHODS

A cross-sectional study design was employed by calculating total workforce supply per NYS county and the proportion of physicians, NPs, and PAs per total number of Medicaid beneficiaries. We extracted the frequencies of all NYS Medicaid beneficiary chronic condition-related ED visits and in-patient admissions. Medicaid beneficiaries were considered to have a chronic condition if there was a claim indicating that the beneficiary received a service or treatment for this specific condition. We calculated the proportion of ED visits/beneficiary for each chronic disease category and the proportion of category-specific in-patient hospitalizations per the number of beneficiaries with that diagnosis.

RESULTS

As the NP/beneficiary proportion increased, ED visits for dual and nondual eligible beneficiaries decreased (p = .007; β = -2.218; 95% confidence interval [CI]: -3.79 to -0.644 and p = .04; β = -2.698; 95% CI: -5.268 to -0.127, respectively).

IMPLICATIONS FOR PRACTICE

Counties with a higher proportion of NPs and PAs had significantly lower numbers of ED visits and hospitalizations for Medicaid beneficiaries.

Need for Nurse Practitioner Fellowships in Ophthalmology in the USA

Medical attention to vision impairment and associated eye care complications are a vital component of daily living and overall well-being. In the United States today, the physician to patient deficit places great strain on the availability of medical attention tenable to patients nationwide; in terms of specialty medicine, this deficit is even more widespread. The field of ophthalmology faced the same physician to patient deficit in 2020, a grim reality that has left many states void of ophthalmic care, rending millions of aging individuals without domestic eye care. The implementation of trained, ophthalmic nurse practitioners (NPs) can fill the needs of this deficit; however, efficient, accredited, and board-approved American ophthalmic fellowships and residencies that secure proper ophthalmic NP transitions from academia to clinical practice are non-existent. Though scant, evidence-based literature presents sound findings that support the efficacy and benefit for superior patient outcomes with care provided by ophthalmic-trained NPs, offering a viable, long-term solution to the need for ophthalmic medical providers across all states without mitigating patient care, emphasizing the great need for the implementation of ophthalmic NP residencies and fellowships to ensure the continuity of impeccable ophthalmic care for all populations.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey

BACKGROUND

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings.

METHODS

Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact.

RESULTS

Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment.

CONCLUSION

This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE

The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs).

RESEARCH DESIGN AND METHODS

Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models.

RESULTS

PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001).

CONCLUSIONS

Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007-2016

OBJECTIVE

Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing.

DESIGN

Temporal ecological study.

SETTING

Non-federal physician offices.

PARTICIPANTS

Patient visits to a physician, PA or NP, spanning years 2007-2016.

METHODS

A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type.

RESULTS

Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers.

CONCLUSIONS

In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.

Advanced providers in pediatric surgery: Evaluation of role and perceived impact

INTRODUCTION

The shortage of medical doctors in certain geographies and certain disciplines, resident work hour limitations and the demonstrated positive impact of advanced providers (nurse practitioners, physician assistants and clinical nurse specialists) on the quality and efficiency of care in numerous specialties have led to broader integration of advanced providers in healthcare organizations. With regard to pediatric surgery, some tertiary centers have successfully implemented 24/7 nurse practitioner coverage for their inpatient services. However, pediatric surgery practices vary throughout North America and the broader presence and function of advanced providers among all practice types and settings has not been characterized previously. The purpose of this survey is to conduct a descriptive evaluation of current pediatric surgical practices in North America with regard to advanced provider coverage and their perceived impact on care delivery and patient satisfaction.

METHODS

A 14-item online survey, approved by the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee, was distributed to all full APSA members (N = 1189, opening rate of 56%), representing the vast majority of pediatric surgeons in North America. The survey investigated the practice characteristics of the responding surgeon, the presence and role of advanced providers in their practice and their perceived impact on patient care. Descriptive statistics were performed to characterize the function of advanced providers in pediatric surgery practices. Further analysis was performed to assess for geographic differences in staffing practices using United States Census Divisions.

RESULTS

A total of 266 pediatric surgeons completed the survey (response rate 22% and 40% considering "email send out" and "email opening" rates respectively), with 47.6% employed at free standing children's hospitals and 41.1% employed at a children's hospital within an adult hospital. Nearly all respondents (N = 244, 91.7%) reported the presence of advanced providers in their practice with nurse practitioners (N = 216) and physician assistants (N = 101) most commonly represented. The majority of advanced providers (N = 189, 77.8%) covered both general surgery and trauma patients. Advanced providers worked nearly equally in the outpatient (N = 219, 89.8%) and inpatient setting (N = 232, 95.1%), though less often in the neonatal (N = 131) or pediatric (N = 126) intensive care unit. Fifteen percent of surgeons (N = 40) reported that advanced providers provided 24/7 coverage within their surgical practice. Surgeons reported that advanced providers had a very positive (75%) or positive (21%) impact on their clinical practice, with none reporting a negative impact. Surgeons also reported that advanced providers had a very positive (74%) or positive (21%) impact on perceived patient satisfaction. The main area in which surgeons reported the most significant impact of associate providers was continuity of care (N = 77), efficiency of service (N = 66) and education of parents and patients (N = 53).

CONCLUSION

Pediatric surgical practices of all types are broadly utilizing advanced providers. Surgeons report that the integration of advanced providers across inpatient and outpatient settings has positively impacted care, advancing both continuity of care and efficiency of service. Advanced providers likely represent part of the solution to delivering quality care in current delivery systems.

STUDY TYPE

Prospective Study/ Survey LEVEL OF EVIDENCE: IV.

Are Physician Associates Less-defined Force Multipliers? Comparative Role Definition of Physician Associates within the Hierarchy of Medical Professionals

Medical field has changed considerably with pressures added on mainly by soaring costs, a decline in the workforce strength and patient expectations. The solution that healthcare systems have come up with is the induction of physician associates (PAs) into the workforce. We aim to compare and contrast PAs with other members of the healthcare teams such as nurses, doctors and assistant physicians to demonstrate the vital role PAs play in the current healthcare environment. With the increased patient load and shrinking medical workforce, there are fears that chronic disease management in primary and secondary care will be threatened. Therefore, health policymakers thought of developing a new mid-level practitioner role (such as PAs, ANPs and APs) that will augment physicians to cater for ever-growing complex medical needs of the patients. The role of PAs is comparable to many healthcare professionals, and one can say that the success of PA programmes has paved the way for the development of different other mid-level practitioner development initiatives. All these roles are there to support primary and secondary care physicians in both inpatient and outpatient settings in helping the patients. PAs are a force multiplier within the healthcare sector and can be seen as a valid solution to staff shortages faced by the healthcare systems around the world. We recommend further studies looking into different aspects of the role of a PA that could further provide our readers with clarity with regard to PAs.

An activity analysis of Dutch hospital-based physician assistants and nurse practitioners

BACKGROUND

The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.

STUDY DESIGN

A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.

METHODS

The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.

FINDINGS

In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.

CONCLUSIONS

NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

Emotion Regulation, Subjective Well-Being, and Perceived Stress in Daily Life of Geriatric Nurses

This daily diary study examined the within-person coupling between four emotion regulation strategies and both subjective well-being and perceived stress in daily life of geriatric nurses. Participants (N = 89) described how they regulated their emotions in terms of cognitive reappraisal and suppression. They also indicated their subjective well-being and level of perceived stress each day over 3 weeks. At the within-person level, cognitive reappraisal intended to increase positive emotions was positively associated with higher subjective well-being and negatively associated with perceived stress. Suppression of the expression of positive emotions was negatively associated with subjective well-being and positively associated with perceived stress. However, cognitive reappraisal intended to down-regulate negative emotions and suppression as a strategy to inhibit the expression of negative emotions were not associated with daily well-being or perceived stress. Off-days were rated as days with higher subjective well-being and lower perceived stress in contrast to working days. At the between-person level, individuals who reported more daily negative affect reported increased suppression of positive emotions, corroborating the within-person findings. Moreover, findings indicated that nurses with more years of experience in the job reported higher subjective well-being and less perceived stress. These results provide insights into important daily emotional processes of geriatric nurses, both at workdays and in their leisure time.

Introduction to four reviews addressing critical topics identified by the 2015 Nurse Practitioner Research Agenda Roundtable: Priorities for policy, workforce, education, and practice

BACKGROUND AND PURPOSE

In 2015, an invitational think tank was convened by the Fellows of the American Association of Nurse Practitioners to update the 2010 Nurse Practitioner (NP) Research Agenda Roundtable. This effort was undertaken to provide guidance for future health care research. The purpose of this article is to introduce the process used for conducting four reviews that address critical topics related to specific research priorities emanating from the 2015 NP Research Agenda Roundtable. The four reviews are published in this issue of Journal of the American Association of Nurse Practitioners (JAANP) to address the state of current research relevant to NP policy, workforce, education, and practice.

METHODS

This introductory article provides an overview of the systematic process used to evaluate the four topical area. The type of review selected, the search strategy, critical appraisal, data extraction, and data synthesis will be further described in the four review articles.

CONCLUSIONS

Four reviews that examine literature regarding specific aims important to NPs will address strengths as well as gaps in the literature.

IMPLICATIONS FOR PRACTICE

The knowledge offered by the four reviews has the potential to inform future research, which will benefit NPs and other health care stakeholders.

A multi-level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network

BACKGROUND

Reducing unnecessary laboratory blood testing in the hospital setting represents a challenge to improve the adequacy of healthcare and a tricky task for teaching hospitals. Our hospital network actively participates in the Choosing Wisely Campaign and is engaged in avoiding unnecessary low value interventions and investigations. We aimed to study whether a multi-level approach combining educational and web-system based interventions, could be effective in reducing laboratory testing and related costs.

METHODS

Multicenter, proof of concept, prospective, observational, before and after study, in a network of public hospitals in Switzerland. All patients admitted between 1 January 2015 and 31 December 2017 were analyzed. A multi-level strategy based on online continuous monitor benchmarking and educational support was applied in the internal medicine services. The primary outcome was a significant reduction in the number of laboratory tests per patient and per day during the hospital stay. Secondary outcomes were reduction in the blood sample volume taken per patient and per day in laboratory costs.

RESULTS

Over the 36 months of the study, 33 309 admissions were analyzed. A significant reduction of laboratory tests per patient and per day of hospitalisation was found:-11%, P-value<0.001; -6%, P-value <0.001. The mean monthly blood volume, per patient and per day of hospital stay and laboratory costs per patient was also significantly reduced: -7%, P-value<0.05; -3%, P-value<0.01, and -17%, P-value<0.01, respectively.

CONCLUSIONS

The obtained reduction in the number of laboratory tests, blood volume withdrawn and related costs, support the idea that an open web-based system, involving all health care providers, coupled with educational interventions, can be helpful in generating awareness of prescriber habits and to catalyze changes in their behaviour. The peer pressure related to the unmasked benchmarking process did probably play a determinant role.

PA use of point-of-care ultrasound: A pilot survey

Limited research exists on PAs and use of point-of-care (POC) ultrasound. This pilot survey sought to determine current views on and use of POC ultrasound in a small group of PAs.

METHODS

The authors developed an anonymous voluntary survey on PA views and use of POC ultrasound. The survey was entered into Qualtrics and e-mailed three times.

RESULTS

Nearly 27% of the subjects use ultrasound with 62% feeling confident in their ability to use ultrasound. The top reason for not using ultrasound was lack of access to a machine (50%). Only 35.3% of those without access to a machine were interested in bringing ultrasound into their practices. Sixty-seven percent of respondents felt that PAs should have standardized ultrasound training.

CONCLUSIONS

Results demonstrate that more research is needed into the applicability of POC ultrasound to all PA practice areas as well as how PAs should be trained in POC ultrasound.

The meanings of the unlicensed assistive personnel role in nursing homes: A triadic job analysis perspective

AIM

This study described and analyzed how older residents, professional nurses and unlicensed assistive personnel (UAP) perceive the meaning and content of the job carried out by UAP in nursing homes (NHs), as a basis for job analysis.

BACKGROUND

Increasing numbers of NH beds and financial restraints have led UAP to become a significant part of the long-term care service system, yet in numerous contexts, the UAP job remains misunderstood and underexplored.

METHOD

The research employed a qualitative phenomenological methodology. Data were collected from 50 semi-structured in-depth interviews with 18 UAP, 15 certified nurses and 17 older NH residents.

RESULTS

We identified six content dimensions in the participants' descriptions regarding the meanings of the roles and duties of the UAP: (a) care for the physical environment, (b) bodily-physical care, (c) psycho-social interpersonal care, (d) professional hierarchy and boundaries, (e) UAP personal traits and (f) UAP skills, or the need for training and professional education.

CONCLUSIONS

Future job definition and formal regulation of UAP should place more focus on the personal characteristics of UAP, as a prerequisite to enter the job.

IMPLICATIONS FOR NURSING MANAGEMENT

The study takes a step forward toward better defining the professional boundaries delineating the meaning of the UAP position.

Creation and Efficacy of a Cadaver-Based Prosection Anatomical Course for Critical Care Advanced Practice Providers

OBJECTIVE

Intensive care units (ICUs) increasingly rely on advanced practice providers (APPs) to care for critically ill patients. Our institutional APPs perceived functional anatomical knowledge deficits. To meet this need, a cadaver-based prosection course was developed. The purpose of our study was to describe and evaluate the learner-perceived course efficacy.

DESIGN

A precourse survey collected participant demographics. Precourse and postcourse surveys assessed perceived confidence in 13 anatomical areas. The postcourse survey also evaluated preparedness to perform ICU procedures and to care for postoperative patients, and additionally, gauged participant satisfaction and opinions. Summary statistics and pre-post survey comparisons were performed using Stata 14.0.

PARTICIPANTS

Twenty-five APPs, all Advanced Practice Registered Nurse certified and working within our tertiary care ICUs, completed the course. Participants practiced in a variety of ICUs, inclusive of neurologic/neurosurgical (4.0%), burn (8.0%), medical (12.0%), trauma (28.0%) and surgical (48.0%), and typically held a Masters of Science in Nursing as his/her highest attained degree. Experience levels ranged from 0 to 8 years.

RESULTS

Precourse survey results confirmed perceived anatomical knowledge deficits, noting median APP scores 3.00 or less, correlating to neutral to very little confidence, in all 13 queried anatomical areas. Wilcoxon signed-rank statistical analysis revealed significantly improved confidence level in anatomic knowledge following course completion in all 13 anatomical areas. Aligning with the improved confidence, most participants felt they were better prepared to perform ICU procedures and care for patients following operative intervention.

CONCLUSION

Cadaver-based anatomical training has significant benefit to ICU APPs perceived knowledge and performance.

Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States

OBJECTIVE

Nurse practitioners (NPs) and physician assistants (PAs) have increasingly broad prescribing authority in the United States, yet little is known regarding how the quality of their prescribing practices compares with that of physicians. The objective of this study was to compare the quality of prescribing practices of physicians and nonphysician providers.

METHODS

A serial cross-sectional analysis of the 2006-2012 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey was performed. Ambulatory care services in physician offices, hospital emergency departments, and outpatient departments were evaluated using a nationally representative sample of patient visits to physicians, NPs, and PAs. Main outcome measures were 13 validated outpatient quality indicators focused on pharmacologic management of chronic diseases and appropriate medication use.

RESULTS

A total of 701,499 sampled patient visits were included during the study period, representing ~8.33 billion visits nationwide. Physicians were the primary provider for 96.8% of all outpatient visits examined; NPs and PAs each accounted for 1.6% of these visits. The proportion of eligible visits where quality standards were met ranged from 34.1% (angiotensin-converting enzyme inhibitor use for congestive heart failure) to 89.5% (avoidance of inappropriate medications among elderly). The median overall performance across all indicators was 58.7%. On unadjusted analyses, differences in quality of care between nonphysicians and physicians for each indicator did not consistently favor one practitioner type over others. After adjustment for potentially confounding patient and provider characteristics, the quality of prescribing by NPs and PAs was similar to the care delivered by physicians for 10 of the 13 indicators evaluated, and no consistent directional association was found between provider type and indicator fulfillment for the remaining measures.

CONCLUSIONS

Although significant shortfalls exist in the quality of ambulatory prescribing across all practitioner types, the quality of care delivered by nonphysicians and physicians was generally comparable.

Return on investment of advanced practice medical degrees: NPs vs. PAs

As the United States faces a predicted physician shortage over the next 2 decades, physician assistants (PAs) and NPs are expected to fill the void. At the same time, because education is expensive, student loan and tuition increases have many potential applicants assessing differences in reimbursement and wondering about their return on investment (ROI). An analysis compared PA and NP salaries by incorporating national salary data, federal income tax, and student loans for a comparative analysis of each career pathway.

METHODS

Salaries were abstracted from the 2012 Bureau of Labor Statistics database. The net present value (NPV) of PA and NP salaries was calculated with a 5% discount rate. Principal and interest for student loans was calculated at a 6% interest fixed-rate loan over 30 years. NPVs were then compared with projected ROI at retirement age. Relative career values were also given to each career choice, based on a retirement age of 65 years, which translates to about 41 years of employment for both PAs and NPs.

RESULTS

PAs' and NPs' educational loans both equalled $129,484 on total repayment. The median annual salary of a PA was $90,930 and $89,960 for an NP. PA data yielded a 5% NPV of $781,323 compared with $764,348 for NPs. Of note, the 5% NPV of a 4-year nursing degree is $728,436.

CONCLUSION

PAs have a slightly higher ROI compared with NPs. These findings may change due to adjustments in nursing training models. Many PA programs allow matriculation immediately after obtaining a bachelor's degree. NP schools often require nursing experience before entering their program. Some schools are considering an accelerated NP program, allowing immediate matriculation after obtaining a bachelor's degree. Because many NP programs have become doctoral degrees, the increased duration of training, higher tuition, and fewer years worked before retirement lower the overall NP ROI. A similar reduction in ROI was considered marginal in PAs who attend residency programs-though these programs are not required for PAs to practice. Comparison of an RN with a 4-year degree to an NP shows little increase in ROI. If interest rates rise, it will become fiscally preferable to remain in a nursing position. Other intangible qualities exist and need further research (for example, weighing the financial aspects with lifestyle or professional satisfaction).

Intrathecal pain management: a team-based approach

Objective

Physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) provide professional services on pain management teams. This review provides an overview of the practical management of chronic pain with intrathecal (IT) therapy using an interprofessional approach (eg, physicians and other health care professionals), with a focus on the contributions of PAs, NPs, and RNs.

Methods

Narrative review based on literature searches of the Medline database and treatment guidelines on the use of IT therapy in the management of patients with chronic pain.

Results

The specific roles and responsibilities of PAs, NPs, and RNs in the management of patients receiving IT therapy vary by practice. In many pain treatment centers, PAs, NPs, and RNs are responsible for patient education, postimplant maintenance, and ongoing supportive care of patients receiving IT therapy. Topics that we address include patient selection, patient expectations and goal setting, medication selection, outcome assessment, and treatment adjustment. Currently, morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker) are the only agents approved by the US Food and Drug Administration for IT analgesia. We provide relevant information on the dosing, titration, and adverse effect management of these medications for PAs, NPs, and RNs responsible for administering IT therapy.

Conclusion

PAs, NPs, and RNs are valuable members of IT pain management teams. Treatment success requires ongoing monitoring of efficacy and adverse effects, with corresponding adjustments to medication selection and dosing, in addition to good communication among the health care professionals involved in patient care.

Determinants of the sustained employment of physician assistants in hospitals: a qualitative study

OBJECTIVES

To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment.

DESIGN

We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together.

SETTING

This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care.

PARTICIPANTS

Participant included staff physicians, residents, PAs and nurses.

RESULTS

The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors.

CONCLUSIONS

10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.

Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential

OBJECTIVES

Many countries are facing provider shortages and imbalances in primary care or are projecting shortfalls for the future, triggered by the rise in chronic diseases and multimorbidity. In order to assess the potential of nurse practitioners (NPs) in expanding access, we analysed the size, annual growth (2005-2015) and the extent of advanced practice of NPs in 6 Organisation for Economic Cooperation and Development (OECD) countries.

DESIGN

Cross-country data analysis of national nursing registries, regulatory bodies, statistical offices data as well as OECD health workforce and population data, plus literature scoping review.

SETTING/PARTICIPANTS

NP and physician workforces in 6 OECD countries (Australia, Canada, Ireland, the Netherlands, New Zealand and USA).

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were the absolute and relative number of NPs per 100 000 population compared with the nursing and physician workforces, the compound annual growth rates, annual and median percentage changes from 2005 to 2015 and a synthesis of the literature on the extent of advanced clinical practice measured by physician substitution effect.

RESULTS

The USA showed the highest absolute number of NPs and rate per population (40.5 per 100 000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Annual growth rates were high in all countries, ranging from annual compound rates of 6.1% in the USA to 27.8% in the Netherlands. Growth rates were between three and nine times higher compared with physicians. Finally, the empirical studies emanating from the literature scoping review suggested that NPs are able to provide 67-93% of all primary care services, yet, based on limited evidence.

CONCLUSIONS

NPs are a rapidly growing workforce with high levels of advanced practice potential in primary care. Workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning.

Nurse Practitioner Autonomy and Satisfaction in Rural Settings

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.

Physician Assistant and Nurse Practitioner Malpractice Trends

Trends in malpractice awards and adverse actions (e.g., revocation of provider license) following an act or omission constituting medical error or negligence were examined. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, physician assistants (PAs), and nurse practitioners (NPs). During 2005 through 2014, there ranged from 11.2 to 19.0 malpractice payment reports per 1,000 physicians, 1.4 to 2.4 per 1,000 PAs, and 1.1 to 1.4 per 1,000 NPs. Physician median payments ranged from 1.3 to 2.3 times higher than PAs or NPs. Diagnosis-related malpractice allegations varied by provider type, with physicians having significantly fewer reports (31.9%) than PAs (52.8%) or NPs (40.6%) over the observation period. Trends in malpractice payment reports may reflect policy enactments to decrease liability.

Improving Access to Head and Neck Cancer Surgical Services through the Incorporation of Associate Providers

Objective

The urgent nature of head and neck cancer referrals often results in overbooked schedules, access delays, and patient, physician, and staff dissatisfaction. The goal of this study is to examine how incorporation of associate providers (APs) into a head and neck tumor clinic (HNTC) can improve access.

Methods

Scheduling data for the Dartmouth-Hitchcock HNTC 2 years prior (January 2011 to December 2012) and 2 years subsequent (January 2013 to December 2014) to program initiation were abstracted, including number of new patients seen per month, third available for new and established patients, overbooked hours, surgeon productivity, and patient satisfaction scores.

Results

New patients seen per month increased from 44 ± 4 to 60 ± 5 ( P < .001). Third available for new patients decreased from 56 ± 4 to 27 ± 2 days and from 43 ± 3 to 35 ± 2 days for follow-ups ( P < .001). Overbooked hours decreased from 14.7 ± 3.1 to 8.6 ± 1.7 hours ( P < .001). Surgeon productivity remained stable (109% ± 11% vs 113% ± 6%, P = .56). Patient satisfaction in seeing APs versus surgeons was comparable (94 ± 2 vs 94 ± 3, P = .79).

Discussion

Incorporation of APs into the HNTC increases the number of new patients seen by the surgeon, decreases wait times for all appointments, and decreases overbooking while maintaining patient satisfaction and surgeon productivity.

Implications for Practice

AP incorporation significantly improves access to head and neck surgical services. With improved access, new cancer patients could start treatment sooner, potentially affecting outcome.

PA and NP productivity in the Veterans Health Administration

This study assessed the 2014 clinical productivity of 5,959 physician assistants (PAs) and nurse practitioners (NPs) in the US Department of Veterans Affairs' Veterans Health Administration (VHA). Total work relative value units divided by the direct clinical full-time equivalent measured annual productivity, and correlated factors were examined using weighted analysis of variance. PAs and NPs in adult primary care roles were more productive than those in other specialties. Both providers were more productive in rural than in nonrural settings and less productive in teaching than nonteaching hospitals. Men were slightly more productive than women but age and years of VHA employment were not correlates of productivity. PAs were more productive when their scope of practice allowed significant autonomy; NP productivity was unaffected by supervisory requirements. PAs and NPs are an important component of the VHA provider workforce, and their productivity correlates with a number of factors. More organizational research is necessary to better understand the contributing roles PAs and NPs provide in a rapidly evolving, vertically integrated, national health delivery system.