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Moffitt AR. Substitution of regulated health professionals, such as doctors and nurses, with unregulated health care workers, such as physician assistants, gives rise to concerns around patient safety and accountability issues: No. J Prim Health Care 2024; 16:220-223. [PMID: 38941249 DOI: 10.1071/hc24077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/30/2024] Open
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Hu X, Coplan B, Barnes H, Smith N, Essary A, Dill M. Physicians working with physician assistants and nurse practitioners: perceived effects on clinical practice. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae070. [PMID: 38919965 PMCID: PMC11196955 DOI: 10.1093/haschl/qxae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/06/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024]
Abstract
Physicians in the United States are increasingly working with physician assistants (PAs) and nurse practitioners (NPs), but little is known about how they perceive working with PAs and NPs affects their clinical practice. We used a new national survey to examine physicians' perceptions of working with PAs and/or NPs on their patient volume, care quality, time use, and workload. Among our analytical sample of 5823 physicians, 59% reported working with PAs and/or NPs. Most reported that PAs and NPs positively affected their clinical practice. Among several findings, physicians working in medical schools and with higher incomes were more likely to indicate that PAs improve their clinical practices in all 4 aspects, while being in specialties with higher women's representation was associated with lower ratings for working with PAs. Native Hawaiian and Pacific Islander physicians and those with higher incomes were more likely to signify that NPs improved their clinical practices in all 4 aspects. These findings provide valuable insights, from the physicians' perspective, on care delivery reform.
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Affiliation(s)
- Xiaochu Hu
- Association of American Medical Colleges, Workforce Studies, Washington, DC 20001, United States
| | - Bettie Coplan
- Northern Arizona University, College of Health and Human Services, Phoenix, AZ 85004, United States
| | - Hilary Barnes
- Widener University, School of Nursing, Chester, PA 19013, United States
| | - Noël Smith
- American Academy of Physician Associates, Research Department, Alexandria, VA 22314, United States
| | - Alison Essary
- Northern Arizona University, College of Health and Human Services, Phoenix, AZ 85004, United States
| | - Michael Dill
- Association of American Medical Colleges, Workforce Studies, Washington, DC 20001, United States
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Huynh J, Alim SA, Chan DC, Studdert DM. Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians. Ann Intern Med 2023; 176:1448-1455. [PMID: 37871318 DOI: 10.7326/m23-0827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
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.
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Affiliation(s)
- Johnny Huynh
- Department of Economics, University of California, Los Angeles, Los Angeles, California (J.H.)
| | - Sahil A Alim
- Yale Law School, New Haven, Connecticut (S.A.A.)
| | - David C Chan
- Department of Health Policy, Stanford University School of Medicine, Stanford, California (D.C.C.)
| | - David M Studdert
- Department of Health Policy, Stanford University School of Medicine, and Stanford Law School, Stanford, California (D.M.S.)
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Kozikowski A, Morton-Rias D, Quella A, Puckett K, Jeffery C, Mauldin S, Goodman J. Public experience with and perspectives on medical care provided by PAs. JAAPA 2023; 36:1-10. [PMID: 37751262 DOI: 10.1097/01.jaa.0000977684.35719.f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Andrzej Kozikowski
- At the National Commission on Certification of Physician Assistants in Johns Creek, Ga., Andrzej Kozikowski is senior research director, Dawn Morton-Rias is president and chief executive officer, Alicia Quella is director of PA relations, Kasey Puckett is a research analyst, Colette Jeffery is a senior research analyst, Sheila Mauldin is a senior advisor, and Joshua Goodman is vice president of research and exam programs. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Boyd W, Witte L, Herman L. Clinical ladders: A potential solution for retaining and promoting PAs. JAAPA 2023; 36:38-42. [PMID: 37493990 DOI: 10.1097/01.jaa.0000944612.51297.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
ABSTRACT As the need for more healthcare providers increases, so does the need for leaders in the healthcare setting. Physician associates/assistants (PAs) are primed to step into these positions, given their key role in the clinical setting. Clinical ladder models are an established system for clinical, administrative, and academic advancement for healthcare providers. Although more research is needed, clinical ladders provide the opportunity for career advancement while helping to promote professional development and improve retention. Moreover, the opportunity for advancement via clinical ladders may help to prevent clinician burnout and turnover by providing more opportunities and career directions.
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Affiliation(s)
- William Boyd
- In the doctor of medical science program at the University of Lynchburg in Lynchburg, Va., William Boyd is director of postgraduate medicine and an assistant professor, Laura Witte is an associate professor, and Lawrence Herman is an adjunct professor. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Kreider KE. Endocrine Edition March 2023. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2023.104605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Stefos T, Moran EA, Poe SA, Hooker RS. Assessing the productivity of PAs and NPs. JAAPA 2022; 35:44-50. [PMID: 36219133 DOI: 10.1097/01.jaa.0000885152.52758.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT The improvement of healthcare efficiency and productivity is of international interest. Following an expansion phase of physician associate/assistant (PA) and NPs employment, the Department of Veterans Affairs (VA) assessed how and where they were being used. Using data from 134 VA medical centers, annual productivity was examined across 30 medical and surgical specialties spanning primary care, mental health, and surgery. PA productivity differences averaged 82 relative value units per full-time employee per year more than NPs, a difference of 4%. In general, PAs were found in higher productivity ranges than NP counterparts. PAs and NPs have statistically similar productivity levels in primary care and mental health. In specialty medicine and surgery, PAs average higher annual productivity than NPs. This analysis provides some utility for managers regarding workforce composition, given the relative productivity of two types of clinicians.
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Affiliation(s)
- Theodore Stefos
- Theodore Stefos was an economist in the US Department of Veterans Affairs (VA) and an assistant professor in Boston University's School of Public Health in Boston, Mass. In the VA's Office of Productivity, Efficiency, and Staffing in West Haven, Conn., Eileen A. Moran is director, and Stacy A. Poe is a program analyst. Roderick S. Hooker is a health policy analyst. The authors have disclosed no potential conflicts of interest, financial or otherwise
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McGrath M, Khamarko K, Noya C. Developing the Diabetes Workforce Through Education of Advanced Practice Nurses. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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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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Chaney A, Beliles G, Keimig A, Porter I. Advanced Practice Provider Care Team Models: Best Practices From an Academic Medical Center. J Ambul Care Manage 2022; 45:126-134. [PMID: 35202029 DOI: 10.1097/jac.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Health care leaders must be innovative to meet the demands of patient access and cost efficiency, all while never compromising patient safety or experience. A clear understanding of the care team model with optimal utilization of all team members is paramount to success. This article discusses 5 nurse practitioner and physician assistant (collectively called advanced practice providers) care team models that regularly occur in health care organizations across the country. Examples of each practice model, a discussion on when each model would be appropriate, as well as data on patient experience and financial return of investment of each model are provided.
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Affiliation(s)
- Amanda Chaney
- Departments of Transplant (Dr Chaney) and Nephrology (Dr Porter), Mayo Clinic, Jacksonville, Florida; and Administration, Mayo Clinic, Jacksonville, Florida (Messrs Beliles and Keimig)
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van den Brink GTWJ, Hooker RS, Van Vught AJ, Vermeulen H, Laurant MGH. The cost-effectiveness of physician assistants/associates: A systematic review of international evidence. PLoS One 2021; 16:e0259183. [PMID: 34723999 PMCID: PMC8559935 DOI: 10.1371/journal.pone.0259183] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.
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Affiliation(s)
- G. T. W. J. van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - R. S. Hooker
- Adjunct Professor, Health Policy, Northern Arizona University, United States of America
| | - A. J. Van Vught
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - H. Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - M. G. H. Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
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Nurse practitioners and barriers to diabetic foot treatment. J Am Assoc Nurse Pract 2021; 32:795-799. [PMID: 31584506 DOI: 10.1097/jxx.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Even with full practice authority, nurse practitioners (NPs) face limitations in care and treatment options. An example of this is current federal law prohibiting NPs from ordering diabetic shoes. PURPOSE This study reviewed the background of this problem, potential impacts on patient health and NP practice, and viable solutions for consideration. METHODS This was a descriptive study of NPs in a northwestern state with full practice authority. An anonymous online survey was used. There were 54 total NP respondents. RESULTS The potential negative patient outcomes associated with restricted NP ability to prescribe diabetic footwear were supported through the literature review and the survey, including increased foot complications and acuity, translating to increased costs. Of the NPs queried, 80% felt inability to prescribe diabetic footwear was limiting to their practice, and 92% felt this affected patient outcomes. Federal legislative changes with support of bipartisan bills allowing NPs to prescribe diabetic footwear could facilitate timeliness and access to care while reducing costs. IMPLICATIONS FOR PRACTICE Legislation affecting NP scope of practice is an important issue with implications related to patient outcomes. Nurse practitioners should continue to support legislation at the federal level to pass bills allowing for NPs to certify orders for diabetic shoes.
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Abstract
Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states. CONTEXT As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids. METHODS This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers. FINDINGS Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs. CONCLUSIONS No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.
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Frazier K, Paez KA, Creek E, Vinci A, Amolegbe A, Hasanbasri A. Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care. Arthritis Care Res (Hoboken) 2021; 74:1593-1601. [PMID: 33973378 DOI: 10.1002/acr.24618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study sought to assess whether patients with autoimmune disease would accept advanced practice providers (APPs) as an option to fill the growing shortage of rheumatologists. METHODS We administered a cross-sectional survey to 500 patients or parents of children who reported having been diagnosed with qualifying autoimmune conditions and who had seen their primary rheumatology providers in the past 6 months. Respondents self-reported whether their primary providers were rheumatologists or APPs. Our analysis compared the attitude and experience of the patients whose primary rheumatology providers were APPs with those of patients whose primary providers were rheumatologists. RESULTS Of respondents, 36.8% reported having APPs as primary rheumatology providers. Patients of APPs were significantly more likely to arrive at their provider's office in 15 minutes or less (p < 0.01) and to be able to schedule routine and urgent appointments sooner (p = 0.02, 0.05). There were no significant differences for overall patient experience of care between provider types. Most patients rated their providers highly, but those who saw rheumatologists rated their providers significantly higher (p < 0.01). APP patients were significantly more likely than rheumatologist patients to prefer to see APPs over rheumatologists (p < 0.01) and to recommend APPs (p < 0.01). CONCLUSIONS APPs may improve access to care, and regardless of provider type, patients rated their overall experience of care similarly. Overall, patient attitudes toward APPs were positive regardless of provider type, although APP patients held more positive overall attitudes toward APPs than did rheumatologist patients.
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Affiliation(s)
- Karen Frazier
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Kathryn A Paez
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Emily Creek
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Arlene Vinci
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Andrew Amolegbe
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Arifah Hasanbasri
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
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Chou LN, Kuo YF, Raji MA, Goodwin JS. Potentially inappropriate medication prescribing by nurse practitioners and physicians. J Am Geriatr Soc 2021; 69:1916-1924. [PMID: 33749843 DOI: 10.1111/jgs.17120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/06/2021] [Accepted: 03/03/2021] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Lin-Na Chou
- Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas, USA.,Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, USA
| | - Yong-Fang Kuo
- Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas, USA.,Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, USA.,Department in Internal Medicine, Division of Geriatrics and Palliative Care, University of Texas Medical Branch, Galveston, Texas, USA.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mukaila A Raji
- Department in Internal Medicine, Division of Geriatrics and Palliative Care, University of Texas Medical Branch, Galveston, Texas, USA.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA
| | - James S Goodwin
- Department in Internal Medicine, Division of Geriatrics and Palliative Care, University of Texas Medical Branch, Galveston, Texas, USA.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA
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Razavi M, O’Reilly-Jacob M, Perloff J, Buerhaus P. Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries. Med Care 2021; 59:177-184. [PMID: 33273295 PMCID: PMC7899223 DOI: 10.1097/mlr.0000000000001477] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences. RESEARCH OBJECTIVE Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). STUDY DESIGN Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. RESULTS Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. CONCLUSIONS There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.
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Affiliation(s)
- Moaven Razavi
- The Heller School for Social Policy and Management, Brandeis University, Waltham
| | | | - Jennifer Perloff
- The Heller School for Social Policy and Management, Brandeis University, Waltham
| | - Peter Buerhaus
- Center for Interdisciplinary Health Workforce Studies, Montana State University, Bozeman, MT
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Pines JM, Zocchi MS, Ritsema TS, Bedolla J, Venkat A. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. Acad Emerg Med 2021; 28:36-45. [PMID: 33107088 DOI: 10.1111/acem.14161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/01/2020] [Accepted: 10/22/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians. METHODS We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history. RESULTS In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history. CONCLUSION Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group.
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Affiliation(s)
- Jesse M. Pines
- From US Acute Care Solutions Canton OHUSA
- The Department of Emergency Medicine Allegheny Health Network Pittsburgh PAUSA
| | - Mark S. Zocchi
- From US Acute Care Solutions Canton OHUSA
- The Heller School for Social Policy and Management Brandies University Waltham MAUSA
| | - Tamara S. Ritsema
- The Department of Physician Assistant Studies The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - John Bedolla
- From US Acute Care Solutions Canton OHUSA
- and Dell Medical School University of Texas at Austin Austin TXUSA
| | - Arvind Venkat
- From US Acute Care Solutions Canton OHUSA
- The Department of Emergency Medicine Allegheny Health Network Pittsburgh PAUSA
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Driving high-functioning clinical teams: An advanced practice registered nurse and PA optimization initiative. JAAPA 2020; 33:1-12. [PMID: 32452967 DOI: 10.1097/01.jaa.0000662400.04961.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid changes in the healthcare marketplace are driving healthcare systems to modify operations by which advanced practice registered nurses (APRNs) and physician assistants (PAs) serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands, resulting in high-functioning clinical teams. LOCAL PROBLEM With the growing number of APRNs and PAs in a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these healthcare providers. METHODS Directors of the APP Best Practice Center developed an internal NP/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service which conducted evaluations to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists. INTERVENTIONS Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and more than 200 individual NP/CNM/CNS/PA interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members. RESULTS Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support. CONCLUSIONS Several recommendations were presented to department leaders about NP/CNM/CNS/PA practice. Departments that implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.
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Moldestad M, Greene PA, Sayre GG, Neely EL, Sulc CA, Sales AE, Reddy A, Wong ES, Liu CF. Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states. J Adv Nurs 2020; 76:3092-3103. [PMID: 32875584 DOI: 10.1111/jan.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS To understand patients' and providers' perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System. DESIGN Qualitative exploratory study (in convergent mixed-methods design). METHODS Semi-structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis. RESULTS We interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers' professional experience outweighed provider type. CONCLUSIONS Patients' preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers' perceptions suggest NPs and physicians are both viable providers for primary care. IMPACT Nurse Practitioners (NPs): practice authority Veterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care delivery United States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much-needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiences.
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Affiliation(s)
- Megan Moldestad
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Preston A Greene
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Emily L Neely
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Christine A Sulc
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Anne E Sales
- VHA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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Nissanholtz-Gannot R, Shapiro E. Community nurses and chronic disease in Israel: Professional dominance as a social justice issue. Nurs Inq 2020; 28:e12376. [PMID: 32845579 DOI: 10.1111/nin.12376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 01/03/2023]
Abstract
Chronic diseases are major causes of health inequalities. Community nurses can potentially make large contributions to chronic illness prevention and management in Israel but may be obstructed by professional dominance of physicians. However, insufficient research exists about community nursing in Israel, and how it may differ from other countries. This study aims to document chronic disease-related community nursing roles in Israel, identify changes and trends in community nursing roles that may increase social justice, and understand how the roles and trends in community health nursing in Israel may differ from developments in other countries. In-depth interviews were performed with 55 Israeli health system professionals, and 692 nurse care-givers were asked open-ended questions. Interview answers were analyzed to find themes and trends. The study found that community nurse roles in Israel have expanded, especially for chronic disease control. Commonalities exist with countries such as the United States and the UK, albeit with important differences. However, continued conflicts with physicians exist, which can limit nurses' contributions to reducing health inequalities. Community nurses' importance is growing. Enabling them to overcome professional dominance and improve chronic disease control can help reduce health inequalities in Israel and elsewhere.
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Affiliation(s)
- Rachel Nissanholtz-Gannot
- Department of Health Systems Management, Ariel University, Ariel, Israel.,Myers-JDC-Brookdale Institute, Smokler Center for Health Policy Research, Jerusalem, Israel
| | - Ephraim Shapiro
- Department of Health Systems Management, Ariel University, Ariel, Israel
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Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants? Med Care 2020; 58:681-688. [PMID: 32265355 DOI: 10.1097/mlr.0000000000001326] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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23
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Fernandes SM, Marelli A, Hile DM, Daniels CJ. Access and Delivery of Adult Congenital Heart Disease Care in the United States. Cardiol Clin 2020; 38:295-304. [DOI: 10.1016/j.ccl.2020.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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24
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Can PAs and NPs manage complex patients? JAAPA 2020; 33:53-54. [DOI: 10.1097/01.jaa.0000684140.98683.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Driving high-functioning clinical teams: An advanced practice registered nurse and physician assistant optimization initiative. J Am Assoc Nurse Pract 2020; 32:476-487. [PMID: 32511193 DOI: 10.1097/jxx.0000000000000415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams. LOCAL PROBLEM With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers. METHODS Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists. INTERVENTIONS Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members. RESULTS Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support. CONCLUSIONS Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.
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26
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Tong WT, Ng CJ, Lee YK, Lee PY. What will make patients use a patient decision aid? A qualitative study on patients' perspectives on implementation barriers and facilitators. J Eval Clin Pract 2020; 26:755-764. [PMID: 31115132 DOI: 10.1111/jep.13161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting. METHODS This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach. RESULTS Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it). CONCLUSIONS Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.
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Affiliation(s)
- Wen Ting Tong
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yew Kong Lee
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping Yein Lee
- Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
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27
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Davidson MB. Second-generation basal insulins to initiate insulin therapy in type 2 diabetes: A need for clinical evidence before incurring increased costs. Diabetes Obes Metab 2020; 22:719-721. [PMID: 32115843 DOI: 10.1111/dom.14016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Mayer B Davidson
- Division of Endocrinology, Department of Internal Medicine, Charles R. Drew University, Los Angeles, California
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Cody R, Gysin S, Merlo C, Gemperli A, Essig S. Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review. BMC FAMILY PRACTICE 2020; 21:38. [PMID: 32066391 PMCID: PMC7025404 DOI: 10.1186/s12875-020-1089-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs. METHODS According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed. RESULTS Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases. CONCLUSION Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.
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Affiliation(s)
- Robyn Cody
- Institute of Primary and Community Care, Schwanenplatz 7, 6004, Lucerne, Switzerland.
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland.
| | - Stefan Gysin
- Institute of Primary and Community Care, Schwanenplatz 7, 6004, Lucerne, Switzerland
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Christoph Merlo
- Institute of Primary and Community Care, Schwanenplatz 7, 6004, Lucerne, Switzerland
| | - Armin Gemperli
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - Stefan Essig
- Institute of Primary and Community Care, Schwanenplatz 7, 6004, Lucerne, Switzerland
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Morgan PA, Smith VA, Berkowitz TSZ, Edelman D, Van Houtven CH, Woolson SL, Hendrix CC, Everett CM, White BS, Jackson GL. Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients. Health Aff (Millwood) 2019; 38:1028-1036. [DOI: 10.1377/hlthaff.2019.00014] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Perri A. Morgan
- Perri A. Morgan is a professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine, in Durham, North Carolina
| | - Valerie A. Smith
- Valerie A. Smith is an assistant professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs (VA) Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
| | - Theodore S. Z. Berkowitz
- Theodore S. Z. Berkowitz is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - David Edelman
- David Edelman is a professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Division of General Internal Medicine, Duke University School of Medicine
| | - Courtney H. Van Houtven
- Courtney H. Van Houtven is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences, Duke University School of Medicine
| | - Sandra L. Woolson
- Sandra L. Woolson is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Cristina C. Hendrix
- Cristina C. Hendrix is an associate professor in the Geriatric Research, Education, and Clinical Center, Durham VA Health Care System and Duke University School of Nursing
| | - Christine M. Everett
- Christine M. Everett is an associate professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine
| | - Brandolyn S. White
- Brandolyn S. White is a research health science specialist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - George L. Jackson
- George L. Jackson is an associate professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
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Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm. J Am Assoc Nurse Pract 2019; 31:93-103. [PMID: 30747805 DOI: 10.1097/jxx.0000000000000155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid changes in health care are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM The Directors of the APP-Best Practice Center conducted assessments of each clinical area at MUSC Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (nurse practitioners/physician assistants) but also in the utilization of APPs to practice to the fullest extent of their license, education, and experience. METHODS By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built while following updated practice laws, compliance/legal standards, and hospital bylaws/regulations. INTERVENTIONS A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS With the APP work force growing, the implementation of electronic medical record systems, and today's health care financial constraints, it is imperative that health care systems standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.
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Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm. JAAPA 2019; 32:1-10. [PMID: 30694959 DOI: 10.1097/01.jaa.0000550293.01522.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rapid changes in healthcare are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM The directors of the APP-Best Practice Center conducted assessments of each clinical area at the Medical University of South Carolina (MUSC) Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (NPs and physician assistants) but also in the use of APPs to practice to the fullest extent of their license, education, and experience. METHODS By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built that follows updated practice laws, compliance/legal standards, and hospital bylaws and regulations. INTERVENTIONS A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS With the APP workforce growing, the implementation of electronic medical record systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.
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Davidson MB, Davidson SJ. Effect of Remote Glucose Monitoring Utilizing Computerized Insulin Dose Adjustment Algorithms: A Pilot Project. Diabetes Ther 2019; 10:523-533. [PMID: 30721451 PMCID: PMC6437238 DOI: 10.1007/s13300-019-0565-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Primary care physicians are often challenged to adjust insulin doses. To facilitate this process, we evaluated in a safety net clinic the work flow and glycemic effects of remote glucose monitoring utilizing Federal Drug Administration (FDA) cleared, Conformité Européenne (CE) registered software that contained computerized algorithms for insulin dose adjustments to help clinicians make dosing decisions for insulin-requiring patients. METHODS Patients taking insulin for at least 6 months with HbA1c levels of at least 8.0% measured glucose levels with a meter attached to their smartphones. Readings were automatically transmitted to a secure, Health Insurance Portability and Accountability Act (HIPAA)-approved server. Values were analyzed every 2-3 weeks and reports, including recommendations for insulin dose changes, were sent to a clinic nurse practitioner (NP) who modified or accepted the recommendations. A staff person contacted patients with the new doses determined by the NP. RESULTS Insulin regimens included basal alone (N = 11), basal/bolus (N = 14), and self-mixed/split (N = 3). Baseline HbA1 levels of 10.0% fell to 8.1% at 3 months (N = 28) and 7.6% at 6 months (N = 17) without any clinic visits for dose adjustments. There were 268 reports which allowed providers to see 268 other patients during these avoided clinic visits. The NP agreed with 82% of the recommendations. The total doses of insulin increased by 24%. No patient experienced severe hypoglycemia or visited an emergency department for hypoglycemia. CONCLUSION Remote glucose monitoring utilizing computerized insulin dose adjustment algorithms saved time for both providers and patients while effectively improving glycemia. FUNDING The Leonard M. Lipman Charitable Trust and Mellitus Health.
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Affiliation(s)
- Mayer B Davidson
- Charles R. Drew University, Los Angeles, CA, USA.
- Mellitus Health Inc., Los Angeles, CA, USA.
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Yu JA, Ray KN, Park SY, Barry A, Smith CB, Ellis PG, Schenker Y. System-Level Factors Associated With Use of Outpatient Specialty Palliative Care Among Patients With Advanced Cancer. J Oncol Pract 2019; 15:e10-e19. [PMID: 30407881 PMCID: PMC7010434 DOI: 10.1200/jop.18.00234] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The proportion of patients with advanced cancer who receive outpatient specialty palliative care (OSPC) is as low as 2.0%. Improved understanding of the system-level factors influencing use of OSPC could inform adaptations to the delivery of palliative care to maximize access. We examined associations between OSPC use among patients with advanced solid tumors and oncology-OSPC clinic colocation and patient travel time to an OSPC clinic. PATIENTS AND METHODS We conducted a retrospective cohort study of patients with advanced solid tumors receiving oncologic treatment between January 1 and December 31, 2016, within a comprehensive cancer center network with well-established, oncology-specific OSPC clinics. Multivariable logistic regression analysis was used to evaluate the associations of clinic colocation and geographic access with OSPC use. RESULTS Of 9,485 patients with advanced solid tumors, 478 (5.0%) received OSPC services in 2016. After controlling for age, sex, marital status, cancer type, insurance, treatment intent, and illness severity, patients whose oncologist practices were colocated with OSPC clinics were more likely to use OSPC (odds ratio [OR], 19.2; 95% CI, 14.1 to 26.2). Compared with patients who lived > 90 minutes from an OSPC clinic, patients with travel times of < 30 minutes (OR, 3.2; 95% CI, 2.2 to 4.6) and 31 to 60 minutes (OR, 2.4; 95% CI, 1.6 to 3.6) were also more likely to use OSPC. CONCLUSION Among patients with advanced solid tumors, colocation of oncology and OSPC clinics and shorter patient travel time were associated with greater odds of using OSPC. Future efforts to increase OSPC use in this population should consider clinic colocation and travel burden.
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Affiliation(s)
- Justin A. Yu
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kristin N. Ray
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Seo Young Park
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | - Peter G. Ellis
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yael Schenker
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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Commentaries on health services research. JAAPA 2018. [DOI: 10.1097/01.jaa.0000546482.10184.2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gandhi JS. Role of Paramedical Staff in a Health Service. Am J Med 2018; 131:e399. [PMID: 30266277 DOI: 10.1016/j.amjmed.2018.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/28/2022]
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Gualano MR, Bert F, Adige V, Thomas R, Scozzari G, Siliquini R. Attitudes of medical doctors and nurses towards the role of the nurses in the primary care unit in Italy. Prim Health Care Res Dev 2018; 19:407-415. [PMID: 29268813 PMCID: PMC6452944 DOI: 10.1017/s1463423617000846] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 09/24/2017] [Accepted: 11/19/2017] [Indexed: 11/07/2022] Open
Abstract
AimAim of the present study was to assess the knowledge of the potential role of nurses in the primary care setting and to analyse the attitudes towards their utilization by nurses and General Practitioners (GPs) in a region of Italy. BACKGROUND Nowadays, in Italy, the role of the nurse in primary care is still under-recognized and most primary care medical offices are managed individually by a physician. METHODS The study consists of a questionnaire-based cross-sectional survey carried out in Piedmont, Italy, between February and September 2015.FindingsWe included 105 participants, 57 nurses and 48 physicians. The presence of a nurse working together with the GP was defined as 'useful' by 54.4% of nurses (versus 60.4% of physicians), as 'essential' by 45.6% of nurses (versus 25.0% of physicians), as 'marginal' by no nurses (versus 14.6% of physicians) and as 'unimportant' by none (P=0.002). Thus, physicians seemed to be less favorable towards a full collaboration and power-sharing with nurses. Furthermore, GPs and nurses showed a different attitude towards the role of nurses in primary care: while nurses highlighted their clinical value, physicians tended rather to recognize them a 'supportive' role. Moreover, only 20.8% of the physicians interviewed stated that they worked with a nurse. At the multivariate analysis, the age class resulted to be a significant predictor of the perception that the presence of a nurse working with the GP is essential: participants >50 years had an OR of 0.03 (P=0.028). Although the primary care organization appears still largely based on a traditional physician-centric care model, the positive attitude of nurses and young GPs towards a more collaborative model of primary care might represent a promising starting point.
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Affiliation(s)
- Maria R. Gualano
- Department of Public Health Sciences, University of Turin, Turin, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences, University of Turin, Turin, Italy
| | - Valeria Adige
- School of Nursing, University of Turin, Turin, Italy
| | - Robin Thomas
- Department of Public Health Sciences, University of Turin, Turin, Italy
| | - Gitana Scozzari
- Department of Public Health Sciences, University of Turin, Turin, Italy
| | - Roberta Siliquini
- Department of Public Health Sciences, University of Turin, Turin, Italy
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Abstract
Background Veterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine’s effectiveness in delivering endocrinology care from Atlanta-based endocrinologists. Methods We conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth. Results Thirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans. Conclusions Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.
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Affiliation(s)
- Timothy Xu
- Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN 55905. .,Emory University, Atlanta, Georgia
| | | | - Sarah Sutton
- Central Alabama Veterans Health Care System, Montgomery, Alabama
| | - Mary Rhee
- Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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