Patient Satisfaction With Primary Care

A Physician Assistant Is Associated With Higher Patient Satisfaction With Outpatient Orthopedic Surgery

Patient satisfaction is increasingly used to assess the quality of care and determine physician reimbursement. Patient characteristics influence patient satisfaction, but the effect of physician practice parameters on satisfaction has not been studied in detail. Outpatient satisfaction scores from 11,059 patients who rated 24 orthopedic surgeons from a single institution were studied. Practice-related parameters were collected in a provider-reported survey. Univariate logistic regressions were used to test the associations between each provider characteristic and the likelihood of receiving a 5-star rating on a selection of 16 Press Ganey patient satisfaction questions. The presence of a physician assistant in the clinic positively affected the 5-star rating for all but 1 of the patient satisfaction questions examined, including overall satisfaction (odds ratio [OR], 1.38; 95% CI, 1.03-1.85; P=.031); the likelihood of being recommended to others (OR, 1.57; 95% CI, 1.16-2.14; P=.004); and friendliness/courtesy (OR, 1.58; 95% CI, 1.17-2.13; P=.003). However, having a fellow or nurse practitioner in the clinic, treating children, productivity (measured as total relative value units), taking trauma call, and provider distance from home were not associated with higher scores for any of the Press Ganey patient satisfaction questions. Having a physician assistant in the clinic is an actionable, practice-specific characteristic that positively affects patient satisfaction on many levels and may ultimately improve the perception of care. [Orthopedics. 2022;45(5):e252-e256.].

Choosing a Provider: What Factors Matter Most to Consumers and Patients?

Enhancing consumer and patient choice has been proposed as a means to improve care quality and reduce health-related costs. Choosing a medical provider is one of the most critical and often complex decisions patients make about their health care. We investigated the perceived importance of factors patients may consider when selecting a practitioner and if rated importance of the factors varies with their characteristics and prior experiences with different types of clinicians (physicians, physician assistants, and nurse practitioners). Participants most often identified medical license, certification, and whether the provider accepts the patients’ health insurance as important, while provider type, others’ recommendations, and online reviews were among the least important. We found wide-ranging differences based on patient characteristics. Prior experience with providers was also a strong determinant of patterns of factors patients considered valuable. Policy-makers, health systems, insurers, and providers need to take into account that patients rely on a range of factors that vary based on their distinct needs, backgrounds, and previous experiences—requiring tailored information to make more informed decisions.

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis

BACKGROUND

Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative.

AIMS

This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders.

RESULTS

Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas.

DISCUSSION

Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change.

CONCLUSION

Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

The Association Between Patient Satisfaction and Mode of Visit (Telemedicine Versus In-Person) in a Large Orthopaedic Practice During the COVID-19 Pandemic Lockdown: A Retrospective Study

Background:

During the novel coronavirus disease 2019 (COVID-19) pandemic, telemedicine was rapidly adopted to provide continued, efficient, and safe medical care. Little is known about patient satisfaction with telemedicine in orthopedics or the factors associated with selection of telemedicine versus face-to-face care. Thus, we examined (1) the association between patient satisfaction and mode of visit (telemedicine versus in-person) and (2) predictors of patient satisfaction in a large orthopedic practice during the onset of the pandemic.

Methods:

We conducted a retrospective cohort study of in-person and telemedicine visits within a large, university-affiliated orthopaedic practice between March 2020 and April 2020 during the onset of the COVID-19 pandemic. Patients who completed a patient satisfaction survey were included. Demographic and other office visit (eg, type of provider and type of visit) data were collected. A Patient Satisfaction Aggregate (PSA, range 0 to 1) score was calculated by taking the average of five patient satisfaction questions. Linear regression was used to examine (1) the association between PSA score and mode of visit and (2) predictors of PSA score.

Results:

A total of 2,049 of 6,515 patient satisfaction surveys were completed and included for analysis, of which 748 had telemedicine visits and 1,301 had in-person visits. No association was found between PSA score and mode of visit with and without adjustment for duration of patient-physician relationship, appointment type (new versus follow-up), provider type (physician versus nonphysician), and provider subspecialty (β_unadjusted = 0.004 [SE = 0.01], P = 0.44; β_adjusted = 0.001 [SE = 0.01], P = 0.92). Predictors of increased PSA score were White race (P = 0.001), >1 year relationship with provider (P_{1-3 years} = 0.01, P_{3-5 years} = 0.04, and P_{5+ years} = 0.002), physician provider (P = 0.004), and foot/ankle provider (P = 0.04), whereas predictors of decreased PSA score were oncology provider (P = 0.02) and spine provider (P = 0.001).

Conclusion:

We found no association between PSA score and mode of visit. Predictors of PSA score included race, duration of patient-physician relationship, provider type, and provider subspecialty.

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey

ABSTRACT

Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Physician Extenders in Hand Surgery: The Patient's Perspective

BACKGROUND

Physician extenders, such as physician assistants (PAs) and nurse practitioners (NPs), have been incorporated into health systems in response to the rising demand for care. There is a paucity of literature regarding patient perspectives toward physician extenders in hand surgery.

METHODS

We anonymously surveyed 939 consecutive new patients before their clinic visit. Our questionnaire assessed patient perspectives toward physician extenders, including optimal scope of practice, the effect of the extender when choosing a hand surgeon, and pay equity for the same clinical services.

RESULTS

Of 939 patients, 784 (84%) responded: 54% were male and 46% were female with a mean age of 44.1 years. Most (65%) patients consider the extender's training background when choosing a hand surgeon, with 31% of all patients considering PAs to have higher training than NPs and 17% the reverse. Patients responded that certain services should be physician-provided, including determining the need for advanced imaging (eg, magnetic resonance imaging), follow-up for abnormal diagnostics, and new patient visits. Patients were amenable to services being extender-provided, including minor in-office procedures, preoperative teaching, and postoperative clinic visits. Patients lacked a consensus toward reimbursement equity for hand surgeons and physician extenders providing the same clinical services.

CONCLUSIONS

Our data suggest that patients presenting to a hand surgeon are comfortable receiving direct care from a physician extender in many, but not all, circumstances. Hand surgeons can use these data when deciding how to use extenders to optimize patient satisfaction and practice efficiency as health care systems become increasingly consumer-focused and value-based.

Choosing between nurse-led and medical doctor-led from private for-profit versus non-for-profit health facilities: A household survey in urban Burkina Faso

Background

Providers’ qualification (Medical doctor [MD] or nurse); type of care facility ownership (for-profit [FP] or not-for-profit [NFP]) may all influence individuals’ healthcare-seeking behavior and therefore merits empirical assessment to provide valuable evidence-informed policy orientation in the present context of private health system development. Previous studies have not examined these factors in combination, especially within the urban context of sub-Sahara Africa, where the private sector is rapidly growing. This study aims to explore factors associated with urban residents’ preferences between private MD-led and private nurse-led outpatient care and how these factors vary by type of private health facility ownership (FP and NFP) and levels of disease severity (severe and non-severe cases).

Methods

A cross-sectional household survey was conducted in July-November 2011 on a random final sample of 2064 adults (646 households). We used a face-to-face interview to capture participants’ choice of provider and their associated factors. A multivariable logistic regression was applied.

Results

For severe conditions, participants, almost equally sought FP and NFP facilities, only 36.4% preferred nurses compared to MDs, while for non-severe cases 53.2% preferred FP facilities and only 29.2% patronized nurses. For non-severe conditions, university educated were more likely to use MDs-led FP compared to nurse-led FP facilities (Odds Ratio [OR] = 4.66, 95% confidence interval [CI] = 2.62–8.30) and MD-led FP over MD-led NFP facilities (OR = 1.03, 95%CI = 1.01–1.04), for severe health conditions. Having insurance predicted MD-led FP preference over nurse-led FP. Furthermore, insurance predicted the preference for MD-led FP over MD-led NFP facilities. Employment did not distinguish participants’ choice of provider.

Conclusion

The findings suggest that, at different levels, MDs and nurses from FP and NFP facilities importantly contribute to health services delivery regardless of the severity of health conditions. The results offer some valuable evidence for policy orientation in the current rising tide of the private system, including workforce development, and practitioners' role definition. We suggested that health insurance mechanism would reinforce the private health services utilization and could enhance progress towards the attainment of Sustainable Development Goals.

Patient Perspectives of Midlevel Providers in Orthopaedic Sports Medicine

BACKGROUND

Midlevel providers (eg, nurse practitioners and physician assistants) have been integrated into orthopaedic systems of care in response to the increasing demand for musculoskeletal care. Few studies have examined patient perspectives toward midlevel providers in orthopaedic sports medicine.

PURPOSE

To identify perspectives of orthopaedic sports medicine patients regarding midlevel providers, including optimal scope of practice, reimbursement equity with physicians, and importance of the physician's midlevel provider to patients when initially selecting a physician.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 690 consecutive new patients of 3 orthopaedic sports medicine physicians were prospectively administered an anonymous questionnaire prior to their first visit. Content included patient perspectives regarding midlevel provider importance in physician selection, optimal scope of practice, and reimbursement equity with physicians.

RESULTS

Of the 690 consecutive patients who were administered the survey, 605 (87.7%) responded. Of these, 51.9% were men and 48.1% were women, with a mean age of 40.5 ± 15.7 years. More than half (51.2%) perceived no differences in training levels between physician assistants and nurse practitioners. A majority of patients (62.9%) reported that the physician's midlevel provider is an important consideration when choosing a new orthopaedic sports medicine physician. Patients had specific preferences regarding which services should be physician provided. Patients also reported specific preferences regarding those services that could be midlevel provided. There lacked a consensus on reimbursement equity for midlevel practitioners and physicians, despite 71.7% of patients responding that the physician provides a higher-quality consultation.

CONCLUSION

As health care becomes value driven and consumer-centric, understanding patient perspectives on midlevel providers will allow orthopaedic sports medicine physicians to optimize efficiency and patient satisfaction. Physicians may consider these data in clinical workforce planning, as patients preferred specific services to be physician or midlevel provided. It may be worthwhile to consider midlevel providers in marketing efforts, given that patients considered the credentials of the physician's midlevel provider when initially selecting a new physician. Patients lacked consensus regarding reimbursement equity between physicians and midlevel providers, despite responding that the physician provides a higher-quality consultation. Our findings are important for understanding the midlevel workforce as it continues to grow in response to the increasing demand for orthopaedic sports care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patients' Experiences with Patient-Centred Care are Associated with Documented outcome of Care Indicators for Diabetes: Findings from the Leuven Diabetes Project

Assessment of diabetes care quality increasingly integrates measurements of patient perceptions. With escalating demand for diabetic services, it is critical to evaluate patients' experiences with patient-centred care and their association with outcome of care indicators. Global satisfaction and experiences with patient-centred care were evaluated in patients with type 2 diabetes. Patients participated in a quality improvement programme set-up as a two-arm clustered randomized trial. The Usual Quality Improvement Programme (UQIP) targeted clinical inertia in primary care physicians. The Advanced Quality Improvement Programme (AQIP) aimed to reduce the rate of clinical inertia and improve the provision of patient-centred care. Objective measures of patient-centred care, including overall satisfaction with care and measures related to health promotion, were associated with mean levels of glycosylated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDLc) and systolic blood pressure (SBP), measured after 18 months of intervention. The patient response rate was 55.4%. Fifty-nine per cent of patients were very satisfied with quality of care. Overall satisfaction scores and patients' experiences with patient-centred care, did not significantly differ between AQIP and UQIP. The association between overall satisfaction with care and HbA1c levels significantly differed between AQIP and UQIP (P = 0.048). Overall satisfaction with care and LDLc levels did not significantly differ between AQIP and UQIP, or among all patients. The association between overall satisfaction with care and SBP levels, significantly differed between AQIP and UQIP (P = 0.004). Positive experiences with support in the use of oral antidiabetic agents were associated with significantly lower levels of HbA1c in all patients (P = 0.006). Positive experiences with information provision on diabetes mellitus were associated with significantly lower levels of LDLc and SBP (P = 0.036 and 0.010, respectively), as were experiences with information provision on medical treatment (LDLc, P = 0.005; SBP, P = 0.003). In conclusion, results show relatively good performance in both overall satisfaction with quality of care and in all patient-centredness measures examined. Overall satisfaction and measures of patient-centred care are associated with improved outcomes of care, although not consistently.

The Impact of Using Mid-level Providers in Face-to-Face Primary Care on Health Care Utilization

BACKGROUND

There has been concern that greater use of nurse practitioners (NP) and physician assistants (PA) in face-to-face primary care may increase utilization and spending.

OBJECTIVE

To evaluate a natural experiment within Kaiser Permanente in Georgia in the use of NP/PA in primary care.

STUDY DESIGN

From 2006 through early 2008 (the preperiod), each NP or PA was paired with a physician to manage a patient panel. In early 2008, NPs and PAs were removed from all face-to-face primary care. Using the 2006-2010 data, we applied a difference-in-differences analytic approach at the clinic level due to patient triage between a NP/PA and a physician. Clinics were classified into 3 different groups based on the percentage of visits by NP/PA during the preperiod: high (over 20% in-person primary care visits attended by NP/PAs), medium (5%-20%), and low (<5%) NP/PA model clinics.

MEASURES

Referrals to specialist physicians; emergency department visits and inpatient admissions; and advanced diagnostic imaging services.

RESULTS

Compared with the low NP/PA model, the high NP/PA model and the medium NP/PA model were associated with 4.9% and 5.1% fewer specialist referrals, respectively (P<0.05 for both estimates); the high NP/PA model and the medium NP/PA model also showed fewer hospitalizations and emergency department visits and fewer advanced diagnostic imaging services, but none of these was statistically significant.

CONCLUSIONS

We find no evidence to support concerns that under a physician's supervision, NPs and PAs increase utilization and spending.

Perceptions of care quality and the effect on patient satisfaction

Purpose

This research models the impact of patient perceptions of care quality on overall patient satisfaction in a rural healthcare organization over a three-year time period. The purpose of this paper is to determine if the factors that influence perceptions of service quality change over time and if the change affects overall patient satisfaction.

Design/methodology/approach

Data were collected for three fiscal years (2012-2014) using a 36-question, Likert-scaled attitudinal survey. Multiple regression analysis was performed to identify which constructs of five different service quality dimensions were statistically significant in predicting overall patient satisfaction. Paired comparison of means and ANOVA F-tests highlighted significant differences across years and demographics.

Findings

Multiple regression models of overall patient satisfaction over a three-year time period had significant repeat variables, indicating salience of the dimensions and constructs of service quality that predict patient satisfaction. However, some dimensions of service quality did not remain significant from one year to another, indicating there may be a gap in the patient service cycle over an extended time frame.

Originality/value

This paper explored the sequential relationship between patient satisfaction survey data and perceptions of service quality over a multi-year time frame. The research focussed on outpatient medical clinics, while the majority of previous studies have focussed on acute care or inpatient stays. A longitudinal study is especially relevant for outpatient clinics where continuity of care is important.

Is a mid-level dental provider model acceptable to potential patients?

OBJECTIVE

This study aims to assess patient attitudes toward mid-level dental providers, known as dental therapists (DTs), by surveying those likely to be their patients. The recent adoption of accreditation standards by the Commission on Dental Accreditation has reignited a debate surrounding the state-by-state legalization of DTs in the United States; while the dental profession is divided on DTs, it is important to understand how potential patients may view the DT model.

METHODS

A questionnaire that asks about oral health experience, and comfort with the model of a dually trained dental therapist-hygienist, based on a provided definition, was administered to 600 patients and their waiting room companions at a large urban university-based dental clinic.

RESULTS

Forty percent of respondents indicated they would be comfortable being treated by a DT for all 7 of the procedures referenced, and over 75% were comfortable with each of 5 procedures. Having caps or crowns placed was the only treatment about which respondents were evenly divided. Factors associated with greater odds of comfort with various procedures include being uninsured and being under the age of 65. Uninsured patients were 1.5 to 2 times more likely than privately insured patients to accept a DT.

CONCLUSIONS

The introduction of mid-level dental providers is a strategy that those lacking regular care appear on the whole to be comfortable with.

Nurse practitioners' job satisfaction in rural versus nonrural areas

PURPOSE

The purpose of this study is to examine the nature of nurse practitioners' (NPs) job satisfaction and its relationship to work conditions in rural versus nonrural areas.

DATA SOURCES

A secondary analysis of data extracted from the 2012 National Sample Survey of Nurse Practitioners. NPs in active practice in clinical settings were included in this study. The final analytic sample consisted of 9010 NPs.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Overall, NPs were satisfied with their positions (satisfied to very satisfied). Both rural and nonrural NPs were most satisfied with the proportion of their time spent in patient care, their level of autonomy, and the respect that they received from other colleagues. Nonrural NPs who said or stated that they performed to the fullest extent of their states' legal scope of practice were more satisfied than nonrural NPs who did not. When nonrural NPs fully utilized their NP skills, their job satisfaction increased. For rural NPs, a similar pattern was found regarding full use of their NP skills. The evidence found in this study reminds us that given the increasing demands for NPs' healthcare services, continuous effort should be made to recruit and retain rural NPs.

Knowledge and Perceptions of College Students Regarding the Physician Assistant Profession

PURPOSE

Physician assistants (PAs) are nationally certified and state-licensed medical professionals who practice medicine on healthcare teams with physicians and other providers. Despite the increasing popularity and utility of the profession, knowledge of the role of PAs remains scarce among many segments of the population. The purpose of this study was to determine the knowledge and perceptions of the PA profession among undergraduate college students, as well as what factors are associated with better knowledge and perception of the profession.

METHODS

Using a cross-sectional survey, information was gathered regarding knowledge and perception of PAs. A total of 364 students were surveyed from randomly selected undergraduate courses at a Connecticut public university.

RESULTS

Knowledge scores were significantly higher (p<0.05) in older students, female students, those with plans to pursue a healthcare career, those majoring in health and human services, and those satisfied with care received from a PA. Significantly better perceptions (p<0.05) of PAs were found in older students, those with plans for a future career in healthcare, those majoring in health and human services, those who received prior care from a PA, and those who were satisfied with prior care from a PA. After a short educational intervention, improvements in perceptions were statistically significant (p<0.001) in the surveyed population.

CONCLUSION

This study identifies areas of needed improvement in knowledge and perception of PAs and also provides impetus for educational and marketing-based interventions to improve knowledge and perception of the PA profession in the college student population.

Using Medicare data to assess nurse practitioner-provided care

BACKGROUND

To mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns.

PURPOSE

This study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician.

METHODS

We performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics.

DISCUSSION

States with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas.

CONCLUSIONS

Approximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.

Improving cancer patient care: development of a generic cancer consumer quality index questionnaire for cancer patients

BACKGROUND

To develop a Consumer Quality Index (CQI) Cancer Care questionnaire for measuring experiences with hospital care of patients with different types of cancer.

METHODS

We derived quality aspects from focus group discussions, existing questionnaires and literature. We developed an experience questionnaire and sent it to 1,498 Dutch cancer patients. Another questionnaire measuring the importance of the quality aspects was sent to 600 cancer patients. Data were psychometrically analysed.

RESULTS

The response to the experience questionnaire was 50 percent. Psychometric analysis revealed 12 reliable scales. Patients rated rapid and adequate referral, rapid start of the treatment after diagnosis, enough information and confidence in the healthcare professionals as most important themes. Hospitals received high scores for skills and cooperation of healthcare professionals and a patient-centered approach by doctors; and low scores for psychosocial guidance and information at completion of the treatment.

CONCLUSIONS

The CQI Cancer Care questionnaire is a valuable tool for the evaluation of the quality of cancer care from the patient's perspective. Large scale implementation is necessary to determine the discriminatory powers of the questionnaire and may enable healthcare providers to improve the quality of cancer care. Preliminary results indicate that hospitals could improve their psychosocial guidance and information provision.

State-granted practice authority: do nurse practitioners vote with their feet?

Nurse practitioners have become an increasingly important part of the US medical workforce as they have gained greater practice authority through state-level regulatory changes. This study investigates one labor market impact of this large change in nurse practitioner regulation. Using data from the National Sample Survey of Registered Nurses and a dataset of state-level nurse practitioner prescribing authority, a multivariate estimation is performed analysing the impact of greater practice authority on the probability of a nurse practitioner moving from a state. The empirical results indicate that nurse practitioners in states that grant expanded practice are less likely to move from the state than nurse practitioners in states that have not granted expanded practice authority. The estimated effect is robust and is statistically and economically meaningful. This finding is in concert with and strengthens the wider literature which finds states that grant expanded practice authority to nurse practitioners tend to have larger nurse practitioner populations.

Patient Perceptions of Pharmacist-Managed Clinics: A Qualitative Analysis

Background:

Pharmacist-managed clinics have consistently demonstrated improvement in patient outcomes. Quantitative research offers the benefit of objective outcomes to track progress toward therapeutic goals at pharmacist-managed clinics. While quantitative studies are readily available in the literature, there is a paucity of qualitative studies to capture the patients' perspectives of pharmacy services.

Objective:

To assess through the use of qualitative research methods patient perceptions of pharmacist-managed services within ambulatory care clinics that operate under a collaborative practice agreement.

Methods:

A semi-structured interview questionnaire was developed, pilot tested, and revised using a focus group of clinical pharmacists. The questionnaire was used to conduct face-to-face patient interviews at 6 pharmacist-managed clinics in central Indiana. English-speaking patients with a minimum of 2 visits with the clinical pharmacist were included in this study. Pharmacist-managed clinics without established collaborative practice agreements were excluded. Patient interviews were conducted by a trained research assistant, audio-recorded, and transcribed verbatim. The interview transcripts were analyzed to identify cross-cutting themes without predetermined definitions via inductive qualitative analysis. Four study investigators independently identified themes using a sample of the transcripts. Additional themes were identified and defined in a series of independent reviews and investigator meetings using the remaining transcripts until theme saturation. All themes were assigned to segments of the interview transcripts according to the consensus definitions.

Results:

A total of 30 interviews were conducted across the clinics. Ten themes from the interview transcripts emerged, including disease state management expertise, patient alliance, practice novelty, accessibility, increased sense of patient well-being, and compassion.

Conclusions:

Patient perceptions from qualitative interviews revealed that pharmacists are viewed as medication experts who provide patient-centered care. This study highlights unique in-depth perspectives from the patient that further support maintenance and expansion of pharmacist-managed services.

The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from a multiple case study design in England and Wales

BACKGROUND

The global response to the rise in prevalence of chronic disease is a focus on the way services are managed and delivered, in which nurses are seen as central in shaping patient experience. However, there is relatively little known on how patients perceive the changes to service delivery envisaged by chronic care models.

OBJECTIVES

The PEARLE project aimed to explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to the models. Design, settings and participants Case study design of seven sites in England and Wales ensuring a range of chronic disease management models. Participants included over ninety patients and family carers ranging in age from children to older people with conditions such as diabetes, respiratory disease, epilepsy, or coronary heart disease.

METHODS

Semi-structured interviews with patients and family carers. Focus groups were conducted with adolescents and children. A whole systems approach guided data collection and data were thematically analysed.

RESULTS

Despite nurses' role and skill development and the shift away from the acute care model, the results suggested that patients had a persisting belief in the monopoly of expertise continuing to exist in the acute care setting. Patients were more satisfied if they saw the nurse as diagnostician, prescriber and medical manager of the condition. Patients were less satisfied when they had been transferred from an established doctor-led to nurse-led service. While nurses within the study were highly skilled, patient perception was guided by the familiar rather than most appropriate service delivery. Most patients saw chronic disease management as a medicalised approach and the nursing contribution was most valued when emulating it.

CONCLUSIONS

Patients' preferences and expectations of chronic disease management were framed by a strongly biomedical discourse. Perceptions of nurse-led chronic disease management were often shaped by what was previously familiar to the patient. At a strategic level, autonomous nursing practice requires support and further promotion to wider society if there is to be a shift in societal expectation and trust in the nurse's role in chronic disease management.

Patient-centeredness and timeliness in a primary care network: baseline analysis and power assessment for detection of the effects of an electronic health record

Electronic health records are expected to improve all six dimensions of quality care identified by the Institute of Medicine (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness). HealthTexas Provider Network, the ambulatory care network affiliated with the Baylor Health Care System in Dallas-Fort Worth, Texas, is implementing a networkwide ambulatory electronic health record (AEHR). To evaluate the quality of care and financial impact of the AEHR implementation, we examined the available indicators for quantitatively measuring performance in each dimension of quality. For patient-centeredness, the primary data source available is the patient satisfaction survey. To achieve a broad view of patient-centeredness, we identified two measures of satisfaction (overall satisfaction with the physician and willingness to refer the physician) to be examined individually and used additional survey items to construct physician interaction and organizational scales. These scales showed good reliability (Cronbach alpha = 0.95 and 0.89, respectively) and predictive ability ranging from 77% to 93% when applied to the overall satisfaction measures. Data from September 2003 to June 2006 showed mean pre-AEHR implementation baseline performance of 22.9 (±3.3) on the 25-point physician interaction scale and 38.0 (±5.8) on the 45-point organizational scale; 70.9% of patients reported excellent satisfaction with their physician, and 97.6% of patients reported willingness to refer. Timeliness data were collected using the same survey. Baseline performance showed that 43.4% of patients waited <2 days between making and keeping an appointment, and 50.6% of patients waited <5 minutes past appointment time. However, 12.5% waited >30 days between making and keeping an appointment, and 14.0% waited >30 minutes past appointment time. The power to detect changes in the patient-centeredness and timeliness measures in the 3-year multiple time series evaluation of the quality and financial impact of the AEHR was investigated and showed that even small changes in these measures will be detectable.

The effect of physician panel size on health care outcomes

An inadequate supply of primary care providers is leading to a crisis in access. Pressures are being placed on primary care practices to increase panel sizes. The impact of these pressures on clinical processes, patient satisfaction and waiting times is largely unknown, although evidence from recent literature shows that longer waiting time results in higher mortality rates and other adverse outcomes. FY2004, Department of Veterans Affairs primary care patient data are used. GLIMMIX and other generalized linear model models illustrate how expanded panel sizes are correlated with clinical process indicators, patient satisfaction and waiting times, controlling for practice, provider and patient characteristics. We generally find that larger panel sizes are related to statistically significant increases in waiting time. However, larger panel sizes appear to have generally small effects on patient process indicators and satisfaction. Panels with more support staff have lower waiting times and small, improved outcomes. We find panels with older and clinically riskier patients have, on average, slightly lower waiting times and increased likelihoods of positive outcomes than panels with younger, healthier veterans. Female veterans appear to have reduced likelihoods of positive outcomes. Higher priority and female veterans also have lower satisfaction. Further study is needed to analyse the impact of potential panel size endogeneity in this system.

Physicians, the Affordable Care Act, and primary care: disruptive change or business as usual?

The Patient Protection and Affordable Care Act 1 (ACA) presages disruptive change in primary care delivery. With expanded access to primary care for millions of new patients, physicians and policymakers face increased pressure to solve the perennial shortage of primary care practitioners. Despite the controversy surrounding its enactment, the ACA should motivate organized medicine to take the lead in shaping new strategies for meeting the nation's primary care needs. In this commentary, we argue that physicians should take the lead in developing policies to address the primary care shortage. First, physicians and medical professional organizations should abandon their long-standing opposition to non-physician practitioners (NPPs) as primary care providers. Second, physicians should re-imagine how primary care is delivered, including shifting routine care to NPPs while retaining responsibility for complex patients and oversight of the new primary care arrangements. Third, the ACA's focus on wellness and prevention creates opportunities for physicians to integrate population health into primary care practice.

Patient satisfaction with nurse practitioner-delivered primary healthcare services

PURPOSE

To identify levels of satisfaction with nurse practitioner (NP)-delivered primary healthcare services and to determine demographic differences in degrees of general satisfaction reported by patients.

DATA SOURCES

The Nurse Practitioner Satisfaction Survey (NPSS), a 28-item, 5-point, Likert-type survey instrument was developed; data from 300 female and male clients over 18 years of age presenting for primary healthcare visits at the employee health department of a not-for-profit hospital in the Southern United States were analyzed.

CONCLUSIONS

Although many studies using a variety of healthcare-related patient satisfaction instruments have demonstrated acceptable patient satisfaction with NPs, few have investigated patient satisfaction with NPs in the outpatient primary care occupational health arena. Overall the population seeking health care was satisfied with NP services. In particular, married or cohabitating subjects reported general satisfaction scores that were statistically significantly higher than those who were single and never married. No other differences were found.

IMPLICATIONS FOR PRACTICE

The provision of on-site, employer-sponsored NP primary healthcare services that are perceived as acceptable and satisfactory to employees and families affords significant opportunity and advantage to both employee and employer. Such benefits include enhanced employee and family wellness, facilitated health promotion, enhanced access to care, reduced illness related to time away from work, improved employee productivity, and reduced overall organizational healthcare costs. Knowledge regarding those characteristics contributing to general satisfaction with NP-delivered care serves to facilitate practice pattern changes within the profession that further enhances the visibility, utilization, and acceptability of NPs as primary care providers.

Pediatric physician assistants: distribution and scope of practice

BACKGROUND

Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited.

OBJECTIVE

To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice.

METHODS

Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties.

RESULTS

Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings.

CONCLUSIONS

PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.

Pediatric nurse practitioners in the United States: current distribution and recent trends in training

OBJECTIVE

To assess the current distribution and training patterns of pediatric nurse practitioners (PNPs).

STUDY DESIGN

Secondary data analysis from the National Association of Pediatric Nurse Practitioners and the 2008 US Census Bureau were used to estimate the distribution of PNPs per 100,000 children. Data on nurse practitioner (NP) graduation and specialty education programs were obtained from the American Association of Colleges of Nursing.

RESULTS

PNPs have the greatest concentration in the New England and mid-Atlantic regions and a narrow band of Midwestern states. States that allow PNPs to practice or prescribe independently do not consistently have a higher density of PNPs per child population. There has been a slight decrease in the proportion of programs that offer PNP training. In the last decade, the proportion of NP graduates pursuing family nurse practitioner education has increased, and the proportion pursuing PNP education has decreased.

CONCLUSION

Workforce planning for the health care of children will require improved methods of assessment of the role of PNPs and the volume of care they provide. Increased use of PNPs in pediatrics will likely require greater effort at recruitment of NPs into the PNP specialty.

Payment regulations for advanced practice nurses: implications for primary care

The shortage of primary care providers (PCPs) in the United States may be worsened with health reform if more individuals receive health insurance coverage. Previous research suggests that Advanced Practice Registered Nurses (APRNs) can provide as high quality care and achieve the same health outcomes as physicians. However, APRNs are usually reimbursed at lower rates than physicians by both Medicare and Medicaid. Private health insurance regulations and Any Willing Provider laws vary from state to state but in general do little to facilitate the ability of APRNs to be reimbursed for their services or to be credentialed as PCPs. To maximize the utilization of APRNs as PCPs, the payment system should be remodeled. A clear regulatory framework and payment rationale are needed along with data on the type and complexity of care provided by various practitioners to increase efficiencies and improve access to health care.

Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care

OBJECTIVE

Many patients are using acid-suppressing drugs (ASD) unnecessary. An insurance company initiated intervention programme aiming at reduction of chronic ASD use, was introduced in primary care-practices. We evaluated the attitude and experiences of the participating patients.

METHODS

A survey was conducted among a random sample of 2376 long-term ASD users using a validated questionnaire that combined CAHPS and QUOTE methodology. Using a psychometric principal component analysis we assessed the role of GPs in three scales: quality of support; communication and conduct; involvement in decisions. Both the importance of and experiences with quality items, transformed into quality impact indices, were measured.

RESULTS

Of 2376 questionnaires distributed, 1808 (76%) were returned, 1270 (54%) were valid. 188 were of patients that participated in the programme. The majority was dissatisfied with the GPs' support: no information about rebound side effects (76%), lifestyle habits (68%), and reasons to stop (50%). Compared to the non-participants 9% more participants stopped ASD use (P = 0.04).

CONCLUSION

A majority of patients on chronic ASD was prepared to participate in the drug-reduction programme. Although 16% succeeded in stopping ASD use, the majority was dissatisfied with the role of the GP. Improved GP support might have make more patients stop using ASD.

Physician assistants and nurse practitioners as a usual source of care

PURPOSE

To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care.

METHODS

Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803).

FINDINGS

Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (beta=-0.22, 95% CI =-0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care.

CONCLUSIONS

Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.

Trust, mistrust, racial identity and patient satisfaction in urban African American primary care patients of nurse practitioners

PURPOSE

To analyze relationships between cultural mistrust, medical mistrust, and racial identity and to predict patient satisfaction among African American adults who are cared for by primary-care nurse practitioners using Cox's Interaction Model of Client Health Behaviors.

DESIGN

A descriptive-correlational study was conducted with a convenience sample of 100 community-dwelling adults.

METHODS

Participants completed the Cultural Mistrust Inventory; Group Based Medical Mistrust Scale; Black Racial Identity Attitude Scale; Trust in Physician Scale; Michigan Academic Consortium Patient Satisfaction Questionnaire; and provided demographic and primary care data.

ANALYSIS

Correlations and stepwise multiple regression techniques were used to examine the study aims and correlational links between the theoretical constructs of client singularity, client-professional interaction, and outcome.

FINDINGS AND CONCLUSIONS

Cox's model indicated a complex view of African American patients' perspectives on nurse practitioners. Participants simultaneously held moderate cultural mistrust of European American providers and mistrust of the health care system, and high levels of trust and satisfaction with their nurse practitioners. One racial identity schema (conformity) and trust of nurse-practitioner (NP) providers explained 41% of variance in satisfaction.

CLINICAL RELEVANCE

An African American patient's own attitudes about racial identity and the client-professional relationship have a significant effect on satisfaction with primary care.

A survey of patient satisfaction in a metropolitan Emergency Department: comparing nurse practitioners and emergency physicians

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16 questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitioner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with the Emergency Nurse Practitioners compared with emergency department doctors.

Public awareness and social acceptability of dental therapists

OBJECTIVES

To investigate public awareness and the social acceptability of the use of dental therapists in dental care.

METHOD

A telephone survey of a representative quota sample of 500 adults (>18 years of age) in South Yorkshire, England.

RESULTS

Fifteen per cent of participants were aware of dental therapists as a professional group, of whom only three people correctly identified their 'permitted duties'. Those without problems of access to care were more likely to report awareness (P < 0.05). Fifty-seven per cent were willing to receive simple restorative treatment from a therapist, with acceptability predicted by being younger [OR 1.016 (95% CI: 1.015-1.017)] and having a perceived need for treatment [OR 1.301 (1.053-1.607)]. Fewer were willing to allow a therapist to restore a child's tooth (47%, P < 0.001, test for paired proportions) with acceptability predicted by being younger [OR 1.016 (1.015-1.017)] and being an irregular attender at the dentist [OR 1.309 (1.138-1.697)]. Forty per cent of participants expected to pay less for treatment provided by therapists with the acceptability of equal costs predicted by having access to care [OR 1.346 (1.017-1.781)].

CONCLUSION

These findings have implications for the use of dental therapists. They question patients' and the public's ability to provide informed consent for the treatment provided by them and identify a need for education of the public on the training and competence of therapists and the rationale for employing skill-mix in dentistry.

Patient Satisfaction with Nurse Practitioner and Physician Services in the Occupational Health Setting

The purpose of this research was to determine if patient satisfaction differed when clinical services were provided by nurse practitioners versus physicians in the occupational health setting. This convenience sample included 129 patients visiting community-based occupational medicine clinics for evaluation of a new work-related injury. There was high satisfaction with both nurse practitioner and physician providers. There was no significant difference in overall patient satisfaction between provider types. Results of this study support a practice model using nurse practitioners as primary providers in the occupational health setting.