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Hall TL, Dickinson LM, Warman MK, Oser TK, Oser SM. Continuous glucose monitoring among nurse practitioners in primary care: Characteristics associated with prescribing and resources needed to support use. J Am Assoc Nurse Pract 2024:01741002-990000000-00237. [PMID: 39046421 DOI: 10.1097/jxx.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) can improve health for people with diabetes but is limited in primary care (PC). Nurse Practitioners (NPs) in PC can improve diabetes management through CGM, but NPs' interest in CGM and support needed are unclear. PURPOSE We describe behaviors and attitudes related to CGM for diabetes management among NPs in PC. METHODOLOGY This cross-sectional web-based survey of NPs practicing in PC settings used descriptive statistics to describe CGM experience and identify resources to support prescribing. We used multivariable regression to explore characteristics predicting prescribing and confidence using CGM for diabetes. RESULTS Nurse practitioners in hospital-owned settings were twice as likely to have prescribed CGM (odds ratio [OR] = 2.320, 95% CI [1.097, 4.903]; p = .002) than private practice; those in academic medical centers were less likely (OR = 0.098, 95% CI [0.012, 0.799]; p = .002). Past prescribing was associated with favorability toward future prescribing (coef. = 0.7284, SE = 0.1255, p < .001) and confidence using CGM to manage diabetes (type 1: coef. = 3.57, SE = 0.51, p < .001; type 2: coef. = 3.49, SE = 0.51, p < .001). Resources to prescribe CGM included consultation with an endocrinologist (62%), educational website (61%), and endocrinological e-consultations (59%). CONCLUSIONS Nurse practitioners are open to prescribing CGM and can improve diabetes management and health outcomes for PC patients. IMPLICATIONS Research should explore mechanisms behind associations with CGM experience and attitudes. Efforts to advance CGM should include educational websites and endocrinology consultations for NPs in PC.
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Affiliation(s)
- Tristen L Hall
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Zeng Z, Yu X, Tao W, Feng W, Zhang W. Efficiency evaluation and promoter identification of primary health care system in China: an enhanced DEA-Tobit approach. BMC Health Serv Res 2024; 24:777. [PMID: 38961461 PMCID: PMC11223419 DOI: 10.1186/s12913-024-11244-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND With Primary Health Care (PHC) being a cornerstone of accessible, affordable, and effective healthcare worldwide, its efficiency, especially in developing countries like China, is crucial for achieving Universal Health Coverage (UHC). This study evaluates the efficiency of PHC systems in a southwest China municipality post-healthcare reform, identifying factors influencing efficiency and proposing strategies for improvement. METHODS Utilising a 10-year provincial panel dataset, this study employs an enhanced Data Envelopment Analysis (DEA) model integrating Slack-Based Measure (SBM) and Directional Distance Function (DDF) with the Global Malmquist-Luenberger (GML) index for efficiency evaluation. Tobit regression analysis identifies efficiency determinants within the context of China's healthcare reforms, focusing on horizontal integration, fiscal spending, urbanisation rates, and workforce optimisation. RESULTS The study reveals a slight decline in PHC system efficiency across the municipality from 2009 to 2018. However, the highest-performing county achieved a 2.36% increase in Total Factor Productivity (TFP), demonstrating the potential of horizontal integration reforms and strategic fiscal investments in enhancing PHC efficiency. However, an increase in nurse density per 1,000 population negatively correlated with efficiency, indicating the need for a balanced approach to workforce expansion. CONCLUSIONS Horizontal integration reforms, along with targeted fiscal inputs and urbanisation, are key to improving PHC efficiency in underdeveloped regions. The study underscores the importance of optimising workforce allocation and skillsets over mere expansion, providing valuable insights for policymakers aiming to strengthen PHC systems toward achieving UHC in China and similar contexts.
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Affiliation(s)
- Zhi Zeng
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
- Office of Policy Research, Chinese Center for Disease Control and Prevention & Chinese Academy of Preventive Medicine, Beijing, China
| | - Xiru Yu
- Institute for Hospital Management, Tsinghua University, Shenzhen, Guangdong, 518055, China
| | - Wenjuan Tao
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Wei Feng
- West China School of Public Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Wei Zhang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, Sichuan, 610041, China.
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Kosar CM, Thapa BB, Muench U, Santostefano C, Gadbois EA, Oh H, Gozalo PL, Rahman M, White EM. Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia. JAMA HEALTH FORUM 2024; 5:e240825. [PMID: 38728021 PMCID: PMC11087831 DOI: 10.1001/jamahealthforum.2024.0825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/07/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.
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Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Bishnu B. Thapa
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ulrike Muench
- Department of Social Behavioral Sciences, University of California at San Francisco School of Nursing, San Francisco
| | - Christopher Santostefano
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emily A. Gadbois
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Hyesung Oh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L. Gozalo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
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Ryskina KL, Liang J, Ritter AZ, Spetz J, Barnes H. State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae018. [PMID: 38426081 PMCID: PMC10901290 DOI: 10.1093/haschl/qxae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Junning Liang
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Ashley Z Ritter
- NewCourtland, Philadelphia, PA 19119, United States
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Joanne Spetz
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, United States
| | - Hilary Barnes
- Widener University School of Nursing, Chester, PA 19013, United States
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Vara-Ortiz MÁ, Marcos-Alonso S, Fabrellas-Padrés N. Experience of primary care nurses applying nurse-led management of patients with acute minor illnesses. Int J Nurs Pract 2023:e13216. [PMID: 37964496 DOI: 10.1111/ijn.13216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/25/2022] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
AIM The aim of this study is to determine the experience of primary health care nurses regarding the application of nurse-led management in patients with acute minor illnesses. BACKGROUND Nursing leadership of care for acute minor illnesses is a new challenge faced by nurses in Spain. DESIGN Qualitative, hermeneutical, interpretive phenomenological approach is used. The Consolidated criteria for reporting qualitative research guidelines were applied. METHODS Twenty primary care nurses participated; three focus group discussions and nine semi-structured interviews were conducted between November 2019 and October 2020. All the focus group discussions and interviews were recorded, transcribed verbatim and analysed using content analysis. RESULTS Seven main themes emerged from the focus group discussions and interviews: concept, perception of the other actors, practice, history and social context, competencies, training, and legality. CONCLUSION The study shows the diversity and complexity of nurses' experience when applying nurse-led management in acute minor illnesses. This work has helped to show the gaps perceived by nurses, including the lack of training in the treatment of conditions historically attended by physicians, the lack of definition of the legal framework and the limitations on nurse prescribing. It also highlighted the power of the nursing profession in terms of autonomy, competencies and role expansion.
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Levin JS, Komanduri S, Whaley C. Association between hospital-physician vertical integration and medication adherence rates. Health Serv Res 2023; 58:356-364. [PMID: 36272112 PMCID: PMC10012217 DOI: 10.1111/1475-6773.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins. DATA SOURCES Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017. STUDY DESIGN We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity. EXTRACTION METHODS We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period. PRINCIPAL FINDINGS The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes. CONCLUSIONS While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.
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Affiliation(s)
| | - Swad Komanduri
- RAND Health Care, RAND Corporation, Santa Monica, California, USA
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Dai ZJ, Zhou JY, Xu ST, Zhang JF, Zhuang CF, Gu PH. Application of continuous nursing care based on hierarchical diagnosis and treatment mode in Stage II cardiac rehabilitation of patients after percutaneous coronary intervention. Front Cardiovasc Med 2022; 9:922449. [DOI: 10.3389/fcvm.2022.922449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo explore the effect of applying continuous nursing care based on hierarchical diagnosis and treatment in Stage II cardiac rehabilitation of patients after percutaneous coronary intervention (PCI) and provide a theoretical basis for clinical nursing intervention.MethodsPatients in PCI postoperative II cardiac rehabilitation were selected and randomly divided into the experimental group (community group), the experimental group (rehabilitation group), and the control group. Patients in the control group received the routine cardiac rehabilitation management scheme, while those in the experimental groups received continuous nursing protocol based on the hierarchical diagnosis and treatment mode. All patients were compared for the cardiac rehabilitation evaluation indexes at discharge and 6 months after discharge.ResultsCompared with the control group, the left ventricular ejection fraction, 6-minute walking distance test, medication compliance, and quality of life were all improved in the two experimental groups, and the differences were statistically significant (P < 0.05). The improvement in the rehabilitation group was more significant than in the community group. There were more patients with high cardiac rehabilitation compliance in the rehabilitation group than in the community group, with the difference being statistically significant (P < 0.05).ConclusionContinuous nursing care rehabilitation based on the hierarchical diagnosis and treatment mode can improve the cardiac function of patients after PCI, enhance their quality of life, and improve their rehabilitation and medication compliance, facilitating their cardiac rehabilitation.
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Park JY, Veenstra DL, Wallick CJ, Marcum ZA. Prescribing Alzheimer's Disease treatments by provider type and geographic region: a comparison among physicians, nurse practitioners, and physician assistants. BMC Geriatr 2022; 22:522. [PMID: 35752783 PMCID: PMC9233396 DOI: 10.1186/s12877-022-03176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background The estimated increase in Alzheimer’s Disease (AD) caseload may present a logistical challenge to the US healthcare system. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly delivering primary care to patients with chronic diseases, the nature of their prescribing of AD medications is largely unknown. The primary objective of this study was to compare the prescribing of AD medications across provider types (physician, NP, and PA) and geographic regions. Methods We conducted a retrospective cohort study using IBM MarketScan® commercial and Medicare supplemental claims to examine unique AD prescriptions prescribed between January 1, 2016, and December 31, 2019. Parallel analysis of prescriptions for another geriatric condition, osteoporosis (OP), was also conducted for comparison. Results A total of 103,067 AD prescriptions and 131,773 OP prescriptions were included in analyses. Physicians prescribed most AD prescriptions (95.65%), followed by NPs (3.37%) and PAs (0.98%). Small differences were identified among individual AD medications prescribed by physicians compared to NP/PAs. NPs/PAs prescribed a significantly higher proportion of AD prescriptions in rural as compared to urban areas (z = 0.023, 95%CI [0.018, 0.028]). Conclusion Minimal variation exists in AD prescribing among physicians, NPs, and PAs, but NPs/PAs prescribe more AD prescriptions in rural areas. NPs/PAs, especially in rural areas, may play critical roles in alleviating projected workforce constraints. Further research assessing AD care, health outcomes, and costs by provider type and region is necessary to better guide healthcare workforce planning for AD care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03176-3.
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Affiliation(s)
- Jenny Y Park
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA. .,US Medical Affairs, Genentech, Inc, 1 DNA Way, South San Francisco, CA, 94080, USA.
| | - David L Veenstra
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | | | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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Capsule Commentary on Muench et. al., Scope-of-practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care. J Gen Intern Med 2021; 36:573. [PMID: 32632791 PMCID: PMC7878597 DOI: 10.1007/s11606-020-06016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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