A case study of nurse management of upper respiratory tract infections in general practice

Déploiement de nouveaux rôles infirmiers au Québec et pouvoir médical

Université de Montréal.Le contexte actuel des systèmes de santé occidentaux réclame que des transformations soient opérées dans les modes d’organisation et de dispensation des soins de santé. Pour faire face à ces nouveaux défis, de nombreux établissements ont introduit de nouveaux rôles infirmiers ayant le potentiel de transformer l’offre de services. Cet article a comme but de mieux comprendre le déploiement de ces nouveaux rôles infirmiers en contexte québécois et d’identifier les facteurs qui favorisent ou entravent leur mise en oeuvre, en portant un intérêt particulier à la dimension du pouvoir médical. Notre analyse montre que l’introduction de nouveaux rôles nécessite que soient redéfinis les espaces d’autorité exercés par la profession médicale sur la prestation de l’ensemble des services de santé, incluant les services infirmiers. La question du pouvoir médical, aussi délicate soit-elle, est d’autant plus importante que la négociation des frontières entre la profession infirmière et la profession médicale se présente comme un incontournable pour maximiser le plein potentiel de ces rôles et atteindre les objectifs poursuivis en termes d’accessibilité, de globalité et de qualité des services.

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE

To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO).

STUDY SETTING/DATA SOURCES

Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000.

STUDY DESIGN

Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics.

RESULTS

On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix.

CONCLUSIONS

Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.