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

Prevalence and Predictors of Multimodal Treatment Among U.S. Adults Newly Diagnosed With ADHD

INTRODUCTION

Although a combined treatment of prescription medication and psychotherapy provides long-term benefits for adults with attention deficit/hyperactivity disorder (ADHD), little is known about the prevalence of receiving such multimodal treatment. This study investigated trends in the prevalence and correlates of multimodal treatment among U.S.-insured adults newly diagnosed with ADHD.

METHODS

495,180 U.S. adults from the Komodo Healthcare Map with newly diagnosed ADHD in 2017-2021 were included. Descriptive statistics were used to estimate trends in the prevalence of treatment (no treatment, prescription-only, psychotherapy-only, or both) within 3 months from the index ADHD diagnosis. Multinomial logistic regression was used to examine patient and provider characteristics associated with ADHD treatment. Analysis was conducted in May 2023.

RESULTS

From 2017 to 2021, the prevalence of newly diagnosed ADHD adults receiving multimodal, prescription-only, and psychotherapy-only treatment within 3 months following their first diagnosis increased from 12.9% to 21.4%, 30.2% to 33.3%, and 18.4% to 20.4%, respectively. Over the same period, the prevalence of newly diagnosed ADHD adults receiving no treatment declined from 38.5% to 25%. Relative to their counterparts, the odds of receiving multimodal ADHD treatment were significantly lower (p<0.05) for men, older adults, adults with multiple co-existing conditions, Medicaid and Medicare beneficiaries, and those living in socially disadvantaged areas. Furthermore, the odds of receiving multimodal treatment were higher (p<0.05) for adults who saw a nurse practitioner, physician assistant, or behavioral care (non-physician) provider on their first visit with an ADHD diagnosis, compared to those who saw a physician.

CONCLUSIONS

25% of newly diagnosed ADHD adults received no treatment in 2021 and 53.7% only received a single-modality treatment-raising concerns about the potential implications of untreated ADHD or insufficient treatment on the persistence of ADHD-related impairments, morbidity, productivity, and downstream healthcare cost. The study also highlighted potential sociodemographic, clinical, and provider disparities in ADHD treatment.

A systematic integrative review of specialized nurses' role to establish a culture of patient safety: A modelling perspective

AIMS

To understand specialized nurses' role in the culture of patient safety and their ability to promote and enforce it within healthcare.

DESIGN

A systematic integrative review using the approach of Whittemore and Knafl.

METHODS

Systematic literature search for qualitative, quantitative and mixed-methods studies, followed by data evaluation, quality assessment, analysis and research synthesis with a narrative perspective. Findings were contextualized within a 'framework for understanding the development of patient safety culture'.

DATA SOURCES

Searches were conducted in PubMed [including MEDLINE], Scopus, CINAHL, Web of Science and EMBASE from Jan 2013 until Sep 2023.

RESULTS

Sixteen studies published in English from six different countries were selected and used for research synthesis. Diverse enabling factors and enacting behaviours influencing specialized nurses' roles to promote patient safety culture were identified, mainly focusing on nurses' workload, professional experiences and organizational commitment. Patient safety outcomes focused on medication management, infection prevention, surveillance process in critical care, oversight on quality and safety of nurses' practice, patient care management, continuity of care, adherence to the treatment plan and implementation of a specialized therapeutic procedure.

CONCLUSION

Specialized nurses can make a significant contribution to promote patient safety culture and support organizational initiatives to prevent adverse events.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Stronger participation and leadership of specialized nurses in initiatives to improve patient safety culture requires appropriate investments and support by policy makers and managers in terms of resources and training.

IMPACT

There is a gap in existing literature on the contribution that specialized nurses can make in promoting patient safety culture. Review results highlight the importance of interprofessional collaboration and teamwork by involving specialized nurses. They inform healthcare policy makers about recognizing their roles and competencies in patient safety culture. Preferred reporting items for systematic reviews and meta-analysis. No patient or public contribution.

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.

Public experience with and perspectives on medical care provided by PAs

OBJECTIVE

We sought to assess public experiences with and perspectives about physician associates/assistants (PAs), who are taking on increasingly important roles in healthcare.

METHODS

We conducted a survey using a Qualtrics panel assessing whether participants (N = 1,388) received care from PAs, their perceptions of the care received, and their intentions of seeking care from PAs in the future.

RESULTS

About 67% of participants reported receiving care from PAs; 61.7% believed PAs have more time to communicate with patients. Most respondents were satisfied with the care received, said they were likely to see a PA again, and recommended PAs. Of those not treated by PAs, 30.6% were willing to receive care from PAs, 43.8% were willing to receive care from PAs for minor medical needs, 21.3% were unsure, and 4.3% were unwilling. Older participants and those with more education had consistently more favorable views.

CONCLUSIONS

Public experiences with and perceptions of PAs are positive. Future research should employ longitudinal designs to assess trends as the PA workforce continues to grow.

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BACKGROUND

The nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.

PURPOSE

The purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.

METHODS

Studies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.

FINDINGS

Seventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.

DISCUSSION

More high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.

The Impact of the Addition of a Physical Therapy Assistant to the Treatment Team for Management of Neck Pain: A Retrospective Analysis of Outpatient Physical Therapy Clinics

Introduction The impact of physical therapy assistants (PTAs) on patient outcomes, mostly in the acute and subacute setting, is well known in the literature. However, no study to date has examined the impact of using PTAs as part of a treatment team in the outpatient setting for common musculoskeletal conditions. The purpose of this study is to determine if physical therapy team composition, either physical therapists (PTs) only or a team consisting of PTs and PTAs, has a significant impact on patient outcomes in adult patients with musculoskeletal neck pain to help investigate an ideal practice pattern for outpatient physical therapy. Methods This is a retrospective cohort study analyzing the impact of physical therapy treatment team composition (PTs only, or team consisting of PTs and PTAs) on pain, active range-of-motion (AROM), and disability outcomes via the Neck Disability Index (NDI) in the conservative treatment of neck pain. All patients were treated with usual physical therapy care. Inclusion criteria involved patients with a diagnosis of neck pain (M48.2), older than 18 years old, a physical therapy evaluation procedure code (97161, 97162, 97163), and at least two visits per bout of physical therapy. Primary outcome measures were pain, bilateral rotation AROM, disability, and number of visits.  Results Included patients (n=195) had an average age of 60.8 years ± 16.1 years with an average number of total physical therapy visits of 7.4 visits ± 4.3 visits (range, 2 visits - 22 visits) with 120 patients (61.5%) treated by a PT only (PT-only group) and 75 patients (38.5%) treated by a team consisting of a PT and a PTA (PTA group). The PT-only group had significantly fewer visits than the PTA group (p<0.001). The PT-only group had a pain improvement of 2.1 points ± 2.3 points whereas the PTA group had a pain improvement of 2.2 points ± 2.4 points with no significant difference between the two groups (p=0.573). The PT-only group (n=46 patients) had an average rotation AROM improvement of 20.0 ± 17.4 degrees whereas the PTA group (n=40 patients) had an average rotation AROM improvement of 16.8 degrees ± 23.0 degrees with no significant difference between the level of rotation AROM improvement between the two groups (p=0.408). Furthermore, there was also no significant difference in the amount of NDI improvement seen in both groups (p=0.594). Conclusion There was no significant difference in patient outcomes for pain, AROM, and disability when PTAs were added to the physical therapy treatment team in the conservative management of neck pain in the outpatient setting. However, patients treated with a treatment team consisting of PTAs had significantly more visits, despite no significant change in outcomes. Randomized controlled trials are needed as the reasons for these findings can be many and require further research.

Clinical Outcomes Associated With the Addition of a Physical Therapist Assistant to a Rehabilitation Team When Treating Musculoskeletal Shoulder Pain in the Outpatient Setting: A Retrospective Cohort Study

Introduction Musculoskeletal shoulder pain (MSP) is a common condition frequently treated in an outpatient setting by a physical therapy rehabilitation team. Treatment teams can consist of physical therapists (PTs) with or without physical therapist assistants (PTAs). It is currently unknown how different physical therapy team compositions can impact patient outcomes in the outpatient setting. The purpose of this study is to examine how the addition of PTAs to a physical therapy treatment team would impact clinical outcomes when treating patients with MSP in the outpatient setting. Methods This study is a retrospective cohort analysis comparing clinical outcomes for pain, active range of motion (AROM), and disability for patients with MSP when treated by physical therapy treatment teams with or without the presence of PTAs. Inclusion criteria were patients treated for MSP in an outpatient physical therapy clinic without a history of shoulder surgery. Depending on the rehabilitation team composition, patients were divided into a PT-only group or a PTA group. Results Total patients (n = 238) had a mean age of 62.6 ± 12.6 years (median: 64 years) with a mean total number of physical therapy visits of 7.8 ± 4.9 visits (median: 7.0 visits). Of the entire cohort, the PT-only group had 100 patients and the PTA group had 138 patients. There was no significant difference in the magnitude of pain improvement (mean: 1.5 versus 1.9 points, p = 0.177), the magnitude of abduction AROM improvement (mean: 17.6 versus 13.9 degrees, p = 0.173), and the magnitude of disability improvement (mean: 18.9 versus 13.4 percentage points, p = 0.221) between the PT-only group and the PTA group. However, the PT-only group had significantly fewer total visits as compared to the PTA group (6.7 versus 8.6 visits, p < 0.001). Conclusion The addition of PTAs to a rehabilitation team when treating patients with MSP in the outpatient setting does not appear to adversely impact pain, AROM, or disability outcomes. However, patients treated only by PTs had significantly less visits with similar outcomes. More research is needed to determine the interplay between cost, healthcare utilization, and patient outcomes to maximize quality care.

Impact of advanced practice providers on characteristics and quality of care of patients with chronic hepatitis B

BACKGROUND

Advanced practice providers (APP) may be able to play a role in improving the linkage to care in patients with chronic hepatitis B (CHB), but data are limited.

AIM

To compare management of patients with CHB under APP-assisted versus physician-only care METHODS: This retrospective analysis identified patients with CHB infection from Optum's de-identified Clinformatics® Data Mart Database (2003-2021) using ICD-9/ICD-10 codes. We compared the proportion of patients with CHB who had adequate evaluation for treatment (defined as ALT, HBV DNA, ± HBeAg), and the proportion of treatment-eligible patients with CHB who received treatment between APP versus physician-only care.

RESULTS

We included 42,140 eligible patients (mean age: 51.9 ± 15.1; 56.1% male). Overall, 34.3% received APP care with increasing utilisation over time. Compared to physician-only care, patients who also received APP care were more likely to have viral co-infection, and more likely to have been seen by a specialist (72.1%). Overall, 62.8% and 56.2% of treatment-eligible patients based on AASLD and EASL guidelines, respectively, received treatment. APP care patients were more likely to be treated (AASLD adjusted HR: 1.18, 95%CI: 1.03-1.34; EASL adjusted HR:1.24, 95%CI: 1.09-1.41) after adjustment for age, sex, race/ethnicity, viral dual infection, baseline cirrhosis/liver cancer, number of HBV DNA and alanine aminotransferase measurements, and physician provider type.

CONCLUSION

Treatment-eligible patients with CHB receiving APP care were more likely to receive antiviral therapy. APP care may help to expand the pool of providers for patients with CHB, and to improve current suboptimal treatment rates.

Physician Associates/Assistants in Primary Care: Policy and Value

Since the new century, primary care physician supply has worsened. Analysts predict that health service demand in the United States will grow faster than physician supply. One strategy is the utilization of physician assistants/associates (PAs). Most PAs work full-time, and approximately one quarter are employed in family medicine/general medicine. PAs deliver primary care services in a team-oriented fashion in a wide variety of settings, including private health systems and community health centers. One fifth work in rural and medically underserved areas. Together PAs and nurse practitioners provide approximately one third of the medical services in family medicine, urgent care, and emergency medicine.

Nurses, physicians and patients' knowledge and attitudes about nurse prescribing

Background

One of the roles that nurses have acquired in recent years is the role of prescribing. This study aimed to investigate the knowledge and attitudes of critical care nurses, physicians and patients about nurse prescribing.

Methods

A descriptive cross-sectional study with the participation of 152 nurses, 53 physicians and 75 patients was carried out. Participants were selected by stratified random sampling from the critical care units of six hospitals in Tabriz, Iran. Demographics and participants’ knowledge and attitudes about nurse prescribing questionnaires were used to collect data. The collected data were analyzed using SPSS-22 software.

Results

The mean scores of total knowledge about nurse prescribing in nurses, patients and physicians’ were 15.41 ± 1.85,16.45 ± 2.31, 14.74 ± 1.7 respectively (from a range of 10 -20), and the mean score of knowledge by physicians was significantly higher than others (P = 0.000) and they had more knowledge about nurse prescribing. The mean scores of the attitudes towards nurse prescribing in nurses, physicians and patients were 40.62 ± 3.68, 37.98 ± 5.92 and 39.38 ± 4.39 respectively (from a range of 10 -50). However, the total mean score of attitudes among nurses was significantly higher than others (P = 0.000) and nurses had more positive attitudes toward prescribing.

Conclusion

The results showed that the participants have a good understanding and attitudes toward nurse prescribing. Nurse prescribing as a new duty and authority can be considered in providing more effective care by specialist nurses. The results of this study can also be used in the future planning of health policy for nurses to have the right to prescribe and ultimately improve the quality of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00888-0.

Preparing physician associates to prescribe: evidence, educational frameworks and pathways

There are approximately 2,850 physician associates (PAs) in the UK, and this number is growing. PAs are unable to prescribe due to an absence of statutory regulation and necessary prescribing legislation. While PAs cannot prescribe, they must have an adequate level of pharmacology knowledge to safely manage patients. There is an expectation that this is taught as part of the core syllabus on PA programmes. The Department of Health and Social Care (DHSC) recently announced the introduction of statutory regulation of Medical Associate Professionals (MAPs) that include PAs under the General Medical Council. With the introduction of regulation, PAs may be able to prescribe as part of their role. A working group is considering how this might be achieved in terms of education and supervision requirements, delivery of the training and scope of practice. This paper explores the current approach to delivering pharmacology across UK PA programmes. We evaluate what constitutes acceptable training and assessment, and determine if programmes have the capacity to prepare students for prescribing rights. We compare UK PA programmes with those in the USA, with the V300 Independent/Supplementary Prescribing course and with the Prescribing Safety Assessment examination.

Recent evidence of nurse practitioner outcomes in a variety of care settings

ABSTRACT

When nurse practitioners (NPs) work to expand their scope of practice through state legislatures, the opposing lobbying groups are often physician-led organizations. The main argument against NP independence and limited scope of practice is that NP care is inherently inferior to that of physicians. However, more than three decades of research demonstrates quality and cost outcomes to be equal to or better than that of physicians. This article reviews a wide range of evidence documenting NP competency, satisfaction, and safety, as well as the challenges and consequences when limiting NP scope of practice. The evidence is clear and has not changed in over 30 years, NPs provide access to effective primary care in a variety of settings, equal in quality outcomes, safety, and cost-effectiveness compared with physicians.

Iranian nurses' attitudes towards the necessity and barriers to developing nurse prescribing roles

Background

Prescribing medication by nurses as an approach to rational drug prescription has been proposed in many countries. Nursing prescribing is an effective measure in the management of critically ill patients admitted to intensive care units (ICU). This study investigated the attitude of ICU nurses towards the necessity and the barriers to developing nursing prescribing.

Materials and methods

In this cross-sectional study, 136 ICU nurses were included by stratified random sampling. The data collection tool was the researcher-made questionnaire. Cronbach’s alpha method was used to evaluate the reliability of the instrument. The validity of the instrument was also verified by the content validity method. To collect the data, the researcher referred to the nurses’ workplace and provided them with a questionnaire and collected it after completion.The collected data were analyzed by IBM SPSS 16 using descriptive and inferential statistics.

Results

It was revealed that 58.8 % of nurses were familiar with the term ‘nursing prescribing’; a majority (92.1 %) of whom considered it vital to develop this role in the ICU. Moreover, 86 % (n = 98) of the nurses assumed that it is possible to implement this role in ICU. The most potential barriers to its implementation were lack of legitimacy, disapproval of physicians, and the reluctance of nursing managers.

Conclusions

Most nurses maintained a positive attitude towards nursing prescribing; hence, its legitimacy seems vital in ICUs. For the development of the ‘nurse prescribing’ role, the Nursing System Organization may be helpful.

Nursing students' attitude and preparedness for nurse prescribing and its relationship with self-efficacy

AIM

The number of countries where nurses are allowed to prescribe has increased over the past two decades. Nursing students' self-efficacy has the main impact on their clinical and cognitive skills. The aim of this study is to determine nursing students' attitudes and preparedness for nurse prescribing and its relationship with their perceived self-efficacy.

DESIGN

The descriptive-correlational study METHODS: This study was conducted at five Nursing and Midwifery schools of Tabriz, Ardebil, Ilam, Ramsar, and Mashhad, Iran from March to July 2018. Through random sampling 250 undergraduate nursing students from the different geographical areas of Iran were selected. The research tool consisted of three parts including demographic information, nurse prescribing questionnaire, and a questionnaire on self-efficacy in patient care.

RESULTS

Nursing students had a positive attitudes and relatively high levels of preparedness for nurse prescribing. However, near to half of the participants (48.4%) mentioned that they have not good knowledge of pharmacology. Also there was a significant positive correlation between the students' self-efficacy and their attitudes and preparedness to nurse prescribing (p < 0.001, rs= 0.467;p = 0.00, rs= 0.633).

CONCLUSIONS

Given the nursing students' positive attitude to and their preparedness for nurse prescribing, it is possible to make them more prepared for this new role by increasing their pharmacological knowledge and improving their accountability, management, and leadership skills.

Potentially inappropriate medication prescribing by nurse practitioners and physicians

BACKGROUND

Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.

OBJECTIVE

We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.

RESEARCH DESIGN

We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.

RESULTS

There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.

CONCLUSIONS

NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.

Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care

BACKGROUND

Nonadherence to medications is costly and improving adherence is difficult, requiring multifactorial solutions, including policy solutions.

OBJECTIVE

The purpose of this study is to evaluate the effect of one policy strategy on medication adherence. Specifically, we examine the effect on adherence of expanding scope-of-practice regulations for nurse practitioners (NPs) to practice and prescribe without physician supervision.

DESIGN

We conducted three difference-in-difference multivariable analyses of commercial insurance claims.

PARTICIPANTS

Patients who filled at least two prescriptions in one of three chronic therapeutic medications: anti-diabetics (n = 514,255), renin angiotensin system antagonists (RASA) (n = 1,679,957), and anti-lipidemics (n = 1,613,692).

MAIN MEASURES

Medication adherence was measured as the proportion of days covered (PDC). We used one continuous (PDC 0-1) and one binary outcome (PDC of > .8), the latter indicating good adherence.

KEY RESULTS

Patients taking anti-diabetic medications had a 1.9 percentage point higher medication adherence rate (p < 0.05) and a 2.7 percentage point higher probability of good adherence (p < 0.001) in states that expanded NP scope-of-practice. Medication adherence for patients taking RASA was higher by 2.3 percentage points (p < 0.001) and 3.4 percentage points (p < 0.01) for both measures, respectively. Patients taking anti-lipidemics saw a smaller, but statistically insignificant, improvement in adherence.

CONCLUSIONS

Results indicate that scope-of-practice regulations that allow NPs to practice and prescribe without physician oversight are associated with improved medication adherence. We postulate that the mechanism for this effect is increased access to health care services, which in turn increases access to prescriptions. Our results suggest that policies allowing NPs to maximally use their skills can be beneficial to patients.

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.

Understanding the role of nurse practitioners, physician assistants and other nursing staff in HIV pre-exposure prophylaxis care in the United States: a systematic review and meta-analysis

BACKGROUND

Although pre-exposure prophylaxis (PrEP) was approved for primary HIV prevention by the Federal Drug Administration in 2012, PrEP utilization has been suboptimal. A body of literature and programs has emerged to examine the role of nurse practitioners (NPs), physician assistants and nursing staff in PrEP care. This review aims to understand the current status of non-physician health providers in PrEP care implementation in the United States.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance, we conducted a comprehensive literature search using multiple databases to identify peer-reviewed articles that examined the role of non-physician health providers in the implementation of PrEP. Four major databases of studies using observational study design, randomized control trials and mixed-method study design were screened from November 2019 to January 2020 were searched. Two independent reviewers examined eligibility and conducted data extraction. We employed random-effects model aims to capture variances of estimates across studies.

RESULTS

A total of 26 studies with 15,789 health professionals, including NPs (18, 95% CI = 14,24%), physician assistants (6, 95% CI = 2, 10%), nursing staff (26, 95% CI = 18-34%), and physicians (62,95% CI = 45, 75%), were included in the analysis. The odds of prescribing PrEP to patients among NPs were 40% (OR = 1.40, 95% CI = 1.02,1.92) higher than that among physicians, while the likelihood of being willing to prescribe PrEP was similar. On the other hand, the odds of being aware of PrEP (OR = 0.63, 95% CI = 0.46, 0.87) was 37% less in nursing professionals than that among physicians.

CONCLUSIONS

Although the limited number and scope of existing studies constrained the generalizability of our findings, the pattern of PrEP care implementation among non-physician health providers was described. To achieve wider PrEP care implementation in the U.S., increasing awareness of PrEP among all health providers including both physicians and non-physicians is a key step.

Utilization of High-Intensity Statins in Patients at Risk for Cardiovascular Events: A National Cross-Sectional Study

BACKGROUND

The 2013 American College of Cardiology/American Heart Association cholesterol guidelines, which identified four groups of patients at risk for atherosclerotic cardiovascular disease events, departed from the target-based approach to managing cholesterol. The impact of these guidelines on high-intensity statin use across the United States is unclear.

STUDY QUESTION

The primary objective was to evaluate the rate of high-intensity potential (HIP) statin use before and after the 2013 guidelines. The secondary objective was to identify predictors of HIP statin use within the study population.

STUDY DESIGN

A national cross-sectional study was conducted using data from the National Ambulatory Medical Care Survey. Office visits involving patients aged 21-75 years where criteria for HIP statin therapy were met were included. Visits involving pregnant patients were excluded.

MEASURES AND OUTCOMES

Prescribing trends of HIP statins were measured from National Ambulatory Medical Care Survey data before and after the 2013 guidelines. Multivariate logistic regression identified variables associated with prescribing HIP statins.

RESULTS

A total of 48,884 visits were included, representing more than 940 million office visits nationally. HIP statins were listed in 9.5% and 16.5% of visits before and after 2013, respectively (odds ratio [OR] 1.88; 95% confidence interval [CI] 1.62-2.20). The strongest predictors of HIP statin use were antihypertensive use (OR 5.38, 95% CI 4.67-6.20), comorbid hyperlipidemia (OR 2.93, 95% CI 2.62-3.29), Black race (OR 0.63, 95% CI 0.49-0.81), and Hispanic ethnicity (OR 0.65, 95% CI 0.52-0.80).

CONCLUSIONS

Prescribing rates for HIP statins increased after the release of the 2013 guidelines. The prescribing rates were lower than expected, especially in Black and Hispanic patients. These observations signify opportunities to improve the quality of care for patients who are at risk for atherosclerotic cardiovascular disease events in the United States.

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

BACKGROUND

Prior studies have found that outpatient antibiotics are commonly prescribed for non-bacterial conditions. It is unclear if national prescribing has changed in recent years given recent public health and antimicrobial stewardship initiatives. This study aimed to describe antibiotic prescribing in United States (U.S.) physician offices.

MATERIALS/METHODS

This was a cross-sectional study of all sampled patient visits in the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was defined as at least one oral antibiotic prescription during the visit as identified by Multum code(s). Patient visits were categorized by U.S. geographic region and season. ICD-9-CM and ICD-10 codes were used to assess diagnoses and categorize antibiotic use as appropriate, possibly appropriate, or inappropriate.

RESULTS

Seven billion visits were included for analysis, with 793,415,182 (11.3%) including an antibiotic. Prescribing rates were relatively stable over the study period (102.9-124.9 prescriptions per 1000 visits); however, 2016 had one of the lowest prescribing rates (107.7 per 1000 visits). The most commonly prescribed antibiotic class was macrolides (25 per 1000 visits). The South region and winter season had the highest antibiotic prescribing (118.2 and 129.7 per 1000 visits, respectively). Of patients who received an antibiotic, 55.9%, 35.7%, and 8.4% were classified as inappropriate, possibly appropriate, and appropriate, respectively. The most common conditions in which antibiotics were prescribed inappropriately included those with no indication in any of the predefined diagnosis codes (40.1%), other skin conditions (17.3%), and viral upper respiratory conditions (13.3%).

CONCLUSIONS

There was no significant reduction in outpatient antibiotic prescribing rates among U.S. outpatients from 2009 to 2016 and prescribing varied by region and season. These data suggest that more than half of antibiotics were prescribed inappropriately, with the majority of antibiotics prescribed with no indication. However, these findings need to be confirmed with robust prospective studies.

Improving psychiatric medication use through the Michigan e-psychopharmacology course for nurse practitioners: A pre-post/follow-up study

PURPOSE

Increasing demands for mental health treatment represent a key opportunity for nurse practitioners (NPs) to provide more psychiatric medication treatment (psychopharmacology). Given this need, NPs could benefit from opportunities to enhance knowledge and skills in psychopharmacology.

DESIGN AND METHODS

A novel videoconference course was developed and tested, with 6 weekly sessions taught by a facilitator and a speaker, evaluated by multiple outcomes.

FINDINGS

Course feasibility and evidence of improved NP confidence and performance in psychopharmacology were both demonstrated.

PRACTICE IMPLICATIONS

Continuing education providers should consider adopting this model for effective and accessible NP psychopharmacology education, potentially expanding NP mental healthcare delivery.

Changes in Psychotropic Prescribing for Patients With Dementia, 2014-2016: Potential implications for Pharmacists

OBJECTIVE

To assess changes in psychotropic pharmacotherapy for patients with dementia over a three-year period.<br/> SETTING: National Ambulatory Medical Care Survey, physician office visits from 2014 to 2016.<br/> PRACTICE DESCRIPTION: Retrospective analysis of publicly available, nationally representative data on patient characteristics; diagnoses, including comorbidities; and treatments, including medications. Included were patients with a diagnosis of Alzheimer's disease or dementia who were 18 years of age or older. No sample exclusions were applied.<br/> INTERVENTION: Time period, comparing calendar year (CY) 2014 versus the calendar years 2015 and 2016 using Pearson chi-square tests.<br/> MAIN OUTCOME MEASURE(S): Prescribing rates of psychotropic medications, grouped by therapy class.<br/> RESULTS: The sample included 647 patients (337 in 2014 and 310 in 2015-2016). A majority (69.5%) of the patients were 75 years of age or older; 62.4% were female. Prescribing rates remained relatively stable for antipsychotics (15.1% in 2014 to 12.9% in 2015-16; P = 0.607); antidepressants (35.0% to 27.7%; P = 0.263); acetylcholinesterase inhibitors (38.6% to 33.9%; P = 0.446); and memantine (19.4% to 16.8%; P = 0.551). Significant increases were noted for sedatives (11.9% to 21.7%; P = 0.037) and anticonvulsants (10.0% to 27.6%, P = 0.001).<br/> CONCLUSION: Clinically significant increases in the prescribing of anticonvulsants and sedatives suggest the possibility that these agents are used to combat behavioral and psychological symptoms of dementia in patients with dementia. Further research is required to assess the rationale, efficacy, and safety of these uses.

Disparities in the Use of Guideline-Based Pharmacotherapy Exist for Atherosclerotic Cardiovascular Disease and Heart Failure Patients Who Have Intellectual/Developmental Disabilities in a Commercially Insured Database

BACKGROUND

Patients who have intellectual/developmental disabilities (IDDs) develop atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) at rates similar to or higher than the general population. They also face disparities accessing and using health care services.

OBJECTIVE

To determine if disparities exist in the use of guideline-based pharmacotherapy (GBP) for ASCVD or HF for adults with IDD.

METHODS

Using the 2014 Clinformatics Data Mart Database, adults with ASCVD or HF were divided into IDD or non-IDD groups. Patients with contraindications for GBP medications were excluded. Use of GBP between IDD and non-IDD groups was examined. Subgroup analysis included comparisons between IDD groups.

RESULTS

For HF, 1011 patients with IDD and 236,638 non-IDD patients were identified. For ASCVD, 2190 IDD and 790,343 non-IDD patients were identified. We found that 47.9%, 35.8%, and 13.1% of IDD and 58.7%, 48.4%, and 18.9% of non-IDD patients had pharmacy claims for statins (P < 0.001), β-blockers (P < 0.001), or antiplatelet therapy (P < 0.001), respectively. For HF, 46.8% and 50.3% of IDD and 59.8% and 55.4% of non-IDD patients had pharmacy claims for β-blockers (P < 0.001) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs; P = 0.003), respectively. In all but one multivariate regression models patients with IDD were less likely to use GBP than patients in the non-IDD group. Subgroup analysis revealed that patients who had Down syndrome had lower GBP use in 4 of the 5 measures.

CONCLUSION AND RELEVANCE

Disparities exist in the use of GBP for patients with IDD with ASCVD or HF. Patients who have an IDD should be examined by clinicians to ensure appropriate access to and use of GBP.

Using buprenorphine to treat patients with opioid use disorder

The US opioid epidemic is a complex problem that has resulted in legislative actions to make treatment more accessible to patients. Physician assistants (PAs) have taken an active role in expanding their scope of practice to keep up with treatment needs. This article describes opioid use disorder in the United States, treatment gaps, safe treatment with buprenorphine, and PA prescriptive authority.

A population profile of older adults with prescription encounters with nurse practitioners and family physicians in Ontario: a descriptive retrospective cohort study

BACKGROUND

Compared with patients in family physician practices, there is a poor understanding at a population level of patients in nurse practitioner practices. The study aim was to use Ontario administrative databases to identify the sociodemographic characteristics and comorbidities of patients aged 65 years and older who were prescribed medications by nurse practitioners and family physicians between 2000 and 2015.

METHODS

This population-based descriptive retrospective cohort study included patients 65 years of age and older with Ontario Health Insurance Plan eligibility and at least 1 prescription encounter with a nurse practitioner or family physician during the study period. Prescription identification of patients permitted their characterization by age, sex, geographical location, rurality, neighbourhood income and comorbidities. Patients were categorized into 3 provider groups on the basis of the percentage of prescription encounters with nurse practitioners versus family physicians.

RESULTS

In 2015, patients in the study cohort with prescriptions by nurse practitioners (n = 25 220) were younger than those with prescriptions by family physicians (40.3% were aged 65-69 yr) and they were more likely to be residents of low-income neighbourhoods (44.0% were in the lowest 2 neighbourhood income quintiles) and to be living outside of central Ontario. In contrast, patients who received prescriptions from family physicians (n = 1 952 904) tended to be older (26.8% were aged ≥ 80 yr), to have higher incomes (21.1% were in the highest neighbourhood income quintile) and to live in urban areas (86.5%). Mean Elixhauser Comorbidity Index scores were consistently lower among patients cared for by nurse practitioners than among those predominantly seen by family physicians (1.30 v. 2.04). The most prevalent conditions were hypertension and diabetes, regardless of provider.

INTERPRETATION

The patient characteristic with the highest variability between providers was geographic residence in the province. Elucidating patterns of care is critical for primary care policy and our results provide baseline data for future health care planning.

Commentaries on health services research

PAs and NPs have broad prescribing authority in the United States, yet little is known about how the quality of their prescribing practices compares with that of physicians. The quality of prescribing practices of physicians, PAs, and NPs was investigated through a serial cross-sectional analysis of the 2006-2012 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Ambulatory care services in physician offices, hospital EDs, and outpatient departments were evaluated using a nationally representative sample of patient visits to physicians, PAs, and NPs. Main outcome measures were 13 validated outpatient quality indicators focused on pharmacologic management of chronic diseases and appropriate medication use. The study sampled 701,499 patient visits during the study period, representing about 8.3 billion visits nationwide. Physicians were the primary provider for 96.8% of all outpatient visits examined; PAs and NPs each accounted for 1.6% of these visits. The proportion of eligible visits in which quality standards were met ranged from 34.1% (angiotensin-converting enzyme inhibitor use for patients with heart failure) to 89.5% (avoidance of inappropriate medications in older adults). The median overall performance across all indicators was 58.7%. On unadjusted analyses, differences in quality of care between PAs, NPs, 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 PAs and NPs 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. Although significant shortfalls exist in the quality of ambulatory prescribing across all practitioner types, the quality of care delivered by PAs, NPs, and physicians was generally comparable.¹.

Medication adherence, costs, and ER visits of nurse practitioner and primary care physician patients: Evidence from three cohorts of Medicare beneficiaries

OBJECTIVE

To compare medication adherence, cost, and utilization in Medicare beneficiaries attributed to nurse practitioners (NP) and primary care physicians (PCP).

DATA

Medicare Part A, B, and D claims and beneficiary summary file data, years 2009-2013.

STUDY DESIGN

We used propensity score-weighted analyses combined with logistic regression and generalized estimating equations to test differences in good medication adherence (proportion of days covered (PDC >0.8); office-based and specialty care costs; and ER visits.

DATA EXTRACTION

Beneficiaries with prescription claims for anti-diabetics, renin-angiotensin system antagonists (RASA), or statins.

PRINCIPAL FINDINGS

There were no differences in good medication adherence (PDC >0.8) between NP and PCP attributed beneficiaries taking anti-diabetics or RASA. Beneficiaries taking statins had a slightly higher probability of good adherence when attributed to PCPs (74.6% vs 75.5%; P < 0.05). NP attributed beneficiaries had lower office-based and specialty care costs and were less likely to experience an ER visit across all three medication cohorts (P < 0.01).

CONCLUSIONS

Examining the impact of NP and PCP provided care on outcomes beyond the primary care setting is important to the Medicare program in general but will also help practices seeking to meet benchmarks under alternative payment models that incentivize higher quality and lower costs.