A new model for nurse practitioner utilization in primary care: increased efficiency and implications

Primary Care Organizational Support for Nurse Practitioner Practice and Emotional Health Care Delivery

OBJECTIVES

Nurse practitioners (NPs) are key to delivery of primary care services. However, poor organizational support for independent NP practice, such as lack of access to clinic resources, may lead to prioritizing patient physical health over emotional health. We investigated the relationship between organizational support for independent NP practice and emotional health care delivery.

METHODS

This was a secondary analysis of cross-sectional survey data collected from 397 NPs in 2017. We measured organizational support for independent NP practice using the independent practice and support subscale of the NP Primary Care Organizational Climate Questionnaire. Emotional health care delivery was measured by asking NPs how frequently they addressed emotional concerns of patients. We utilized multilevel mixed effects linear regression models, adjusting for NP and practice covariates.

RESULTS

Controlling for NP age, gender, marital status, race, and ethnicity, along with practice setting and size, as the independent practice and support score increased, NPs reported addressing emotional concerns of patients more frequently (beta = 0.34, 95% confidence interval = 0.02-0.66, P = 0.04). This indicates that as organizations provided more support for independent NP practice, NPs were able to more frequently address emotional concerns of patients.

CONCLUSIONS

Organizational support for independent NP practice is associated with addressing emotional concerns of patients. To support NP practice, primary care organizations should ensure that NPs manage patients independently and have access to ancillary staff and support for care management.

Racial and ethnic disparities in ED use among older adults with asthma and primary care nurse practitioner work environments

Background

Nurse practitioners (NPs) increasingly deliver primary care in the United States. Yet, poor working conditions strain NP care. We examined whether racial/ethnic health disparities in ED visits among older adults with asthma are moderated by primary care NP work environments.

Methods

Survey data on NP work environments in six states were collected from 1,244 NPs in 2018-2019. 2018 Medicare claims data from 46,658 patients with asthma was merged with survey data to assess the associations of all-cause and ambulatory care sensitive conditions (ACSC) ED visits with NP work environment and race/ethnicity using logistic regression.

Results

NP work environment moderated the association of race (Black patients versus White patients) with all-cause (odds ratio [OR]: 0.91; p-value = 0.045) and ACSC (OR: 0.90; p-value = 0.033) ED visits.

Conclusions

Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with favorable NP work environments.

Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas

INTRODUCTION

The prevalence of substance use disorders (SUDs) is growing among older adults, and older adults in rural areas face disparities in access to SUD care. Rural older adults with SUDs commonly have comorbid chronic conditions that puts them at risk for frequent acute healthcare utilization. In rural areas, primary care for patients with SUDs are increasingly provided by nurse practitioners (NPs), and quality primary care services may decrease ED visits in this population. Yet, NP-delivered primary care for rural older adults with SUDs may be limited by work environment barriers, which include lack of support, autonomy, and visibility. This study assessed the relationship between the NP work environment and ED utilization among rural older adults with SUDs.

METHODS

This was a secondary analysis of cross-sectional data from a large survey of NPs in six U.S. states merged with Medicare claims. The study measured the NP work environment by the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which measure 1) independent practice and support, 2) NP-physician relations, 3) NP-administration, and 4) professional visibility. Multilevel logistic regression models, adjusted for practice and patient covariates, assess the relationship between the NP work environment and all-cause ED use.

RESULTS

The sample included 1152 older adults with SUDs who received care at 126 rural NP primary care practices. NP independent practice and support at the practice was associated with 49 % lower odds of all-cause ED visits among older adults with SUDs. There were no relationships between the other NP-PCOCQ subscales and all-cause ED visits.

CONCLUSIONS

Organizational support for NP independent practice is associated with lower odds of all-cause ED utilization among rural older adults with SUDs. Practice administrators should ensure that NPs have access to support and resources to enhance their ability to care for rural older adults with SUDs. Ultimately, these practice changes could reduce ED utilization and health disparities in this population.

Enablers, Barriers, and Contributions of Pediatric Nurse Practitioners to Ambulatory Specialty Care

INTRODUCTION

The objective of this study was to explore the enablers of and barriers to the contribution of nurse practitioners (NPs) in pediatric specialty care.

METHOD

A total of 11 NPs in pediatric medical specialties were interviewed regarding teamwork, communication, documentation, satisfaction, overall role, and perception of the value they contribute to care.

RESULTS

Themes were identified related to structural and organizational enablers and barriers that facilitate or hinder the NPs' contribution to pediatric specialty care.

DISCUSSION

The findings of this study can provide a better understanding of the role of NPs caring for pediatric patients in the specialty setting and can also help guide organizational environments to maximize the potential of pediatric NPs to positively affect patient care.

A Markov chain model for analysis of physician workflow in primary care clinics

This paper studies physician workflow management in primary care clinics using terminating Markov chain models. The physician workload is characterized by face-to-face encounters with patients and documentation of electronic health record (EHR) data. Three workflow management policies are considered: preemptive priority (stop ongoing documentation tasks if a new patient arrives); non-preemptive priority (finish ongoing documentation even if a new patient arrives); and batch documentation (start and finish documentation when the desired number of tasks is reached). Analytical formulas are derived to quantify the performance measures of three management policies, such as physician's daily working time, patient's waiting time, and documentation waiting time. A comparison of the results under three policies is carried out. Finally, a case study in a primary care clinic is carried out to illustrate model applicability. Such a work provides a quantitative tool for primary care physicians to design and manage their workflow to improve care quality.

Perspectives of Quebec Primary Health Care Nurse Practitioners on Their Role and Challenges in Chronic Disease Management: A Qualitative Study

BACKGROUND

Primary health care nurse practitioners (PHCNPs) can play a key role in chronic disease management. However, little is known about the challenges they face.

PURPOSE

The study aimed to describe PHCNPs' perspectives on their role for patients with chronic health conditions, the barriers they face, and facilitating factors.

METHODS

A qualitative descriptive exploratory study was conducted with 24 PHCNPs in the Canadian province of Quebec.

RESULTS

PHCNPs believe that they are in an optimal position to address the needs of patients with chronic health conditions, especially in providing self-management support. However, PHCNPs reported feeling pressured to practice according to a biomedical model and to constantly defend their role in chronic disease management. They feel that they are frequently being diverted from their role to compensate for the lack of family doctors. PHCNPs made concrete recommendations to optimize their autonomous practice and quality of care: promoting strong interprofessional communication skills, genuine mentoring relationships between PHCNPs and partner physicians, managers upholding the full scope of PHCNPs' practice, and a more flexible legislative framework.

CONCLUSIONS

The original conception of PHCNPs as health professionals with unique characteristics is at stake. The factors that should be targeted to support the autonomy of PHCNPs were identified.

Nurse Practitioner Practice Environments in Primary Care and Quality of Care for Chronic Diseases

BACKGROUND

The chronic disease burden in the United States represents a significant challenge for the primary care system. The nurse practitioner (NP) workforce can help meet the demand for care; however, organizational barriers such as poor practice environments prevent NPs from delivering high quality care.

OBJECTIVES

We investigated the relationship between NP practice environments and quality of care for chronic diseases.

RESEARCH DESIGN

We fit regression models to assess cross-sectional associations between claims-based quality measure performance and survey data on NP practice environments in Massachusetts.

SUBJECTS

We used survey data from 221 primary care NPs from 118 practices. We obtained quality of care data for patients with asthma, diabetes, and cardiovascular disease.

MEASURES

The Nurse Practitioner Primary Care Organizational Climate Questionnaire was used to measure practice environments with its following 4 subscales: NP-Physician Relations, Independent Practice and Support, Professional Visibility, and NP-Administration Relations. Three Healthcare Effectiveness Data and Information Set measures were used to evaluate the quality of care.

RESULTS

A 1-SD increase in the organizational-level NP-Administration Relations subscale score was associated with a near doubling of the odds of receiving medication management for asthma. A 1-SD increase in the organizational-level Independent Practice and Support subscale score was associated with a 60% increase in the odds of receiving recommended screening for cardiovascular disease. There was no impact on diabetes care measure.

CONCLUSIONS

NP practice environment affected the quality of care for 2 chronic conditions. Efforts should be implemented to improve NP practice environment to potentially improve care quality.

Role of advanced nurse practitioners in the care pathway for children diagnosed with leukemia

PURPOSE

The development of advanced nursing practices (ANP) can meet challenges presented by evolving needs of health care. We aimed at describing the approach taken to implement ANP in a pediatric oncology-hematology unit.

METHOD

The Participatory, Evidence-informed, Patient-centered Process for Advanced practice was considered as a conceptual framework for the development, implementation and evaluation of the nursing role. Successive steps were taken for identifying patients and family needs, defining the health care priorities, and establishing a new health care model.

RESULTS

The seven steps of the PEPPA framework were carried out over a year and contributed to the identification of the tasks and the role of the advanced nurse practitioner in the patient care pathway. The implementation of ANP was gradually achieved with the development of new evidenced-based health care procedures. The subsequent approval of a contract specification for advanced nurse practitioners facilitated the onset of a specific consultation, which facilitated a holistic approach.

CONCLUSION

The impact of the implementation can be appreciated at different levels: i) the patient and his or her family, with improvement of communication and continuity of care; ii) the interdisciplinary team, with development of a dynamic and greater motivation of the health care providers; and iii) the profession, with a greater recognition of the competencies and conceptualization of the new role. An assessment of the process, the structure and the results should be carried out to validate the role of the advanced nurse practitioner throughout the long journey of a child with leukemia.

Attitudes of medical doctors and nurses towards the role of the nurses in the primary care unit in Italy

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.

Under-diagnosed chronic kidney disease in Jordanian adults: prevalence and correlates

BACKGROUND

Jordan has no relevant database or registry by which chronic kidney disease (CKD) would be early identified. The purpose of the present study is to uncover the prevalence of CKD in a national sample of Jordanian patients at high risk and examine the association of CKD with demographic and clinical factors.

METHODS

This is a cross-sectional, correlational study that involved 540 outpatients at high risk for CKD. Demographic and clinical data were obtained in the period from September 2013 to March 2014. Prevalence of CKD was defined based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Classification of CKD using estimated glomerular filtration rate. Associations of CKD and demographic and clinical factors were examined using bivariate analysis.

RESULTS

The majority of the sample were females (64%), their mean age (±SD) was 55.0 ± 12.5 years, their mean eGFR (±SD) was 116.0 ± 47.5. One third of patients had eGFR of 23.5%, 5.4%, 0.7% and 0.7% which corresponds with mild, moderate, severe and very severe reduction in eGFR, respectively. Ageing, being male, unemployment, packs/years of smoking, co-morbidities [hypertension (HTN), diabetes mellitus (DM) and cardiovascular disease] and low high density lipoprotein (HDL) correlated positively with development of CKD.

CONCLUSION

This study demonstrates a high rate of under-diagnosed CKD among Jordanians. Several demographic and clinical factors are linked with the development of CKD. Policymakers and healthcare providers need to establish an evidence-based practice project to prevent and screen for CKD in Jordan.

An overview of the outcomes and impact of specialist and advanced nursing and midwifery practice, on quality of care, cost and access to services: A narrative review

OBJECTIVES

This paper presents the results of a systematic rapid review and narrative synthesis of the literature of the outcomes and impact of specialist and advanced nursing and midwifery practice regarding quality of care, cost and access to services.

DESIGN

A rapid review was undertaken of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses' and midwives' specialist and advanced practice roles.

DATA SOURCES

A search of the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE) was undertaken from 2012 to 2015. The study also included primary data collection on the perceived impact of specialist and advanced practice nursing and midwifery roles and enablers and barriers to these roles using semi-structured interviews. These are not included in this paper.

REVIEW METHOD

To facilitate a systematic approach to searching the literature, the PICO framework, was adapted.

RESULTS

The database search yielded 437 articles relevant to the analysis of specialist and advanced practice in relation to quality care, cost and access to services with additional articles added in a manual review of reference lists. In the final review a total of 86 articles were included as they fulfilled the eligibility criteria.

CONCLUSION

The evidence presented in the 86 articles indicates that nursing and midwifery practitioners continue to be under-utilised despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on cost. Results point to continued difficulties associated with accurate measurement of the impact of these roles on patient outcomes. This review demonstrates that there is a need for robust measurement of the impact of these roles on patient outcomes.

Improving the care of veterans: The role of nurse practitioners in team-based population health management

BACKGROUND AND PURPOSE

Improving healthcare delivery for U.S. veterans is a national priority. The Veterans Health Administration (VHA) employs a variety of team-based, population health strategies to address critical issues in veterans' health including the effective management of chronic disease. Nurse practitioners (NPs) are integral members of the VHA patient care team with a substantial role to play in the organization and delivery of healthcare services for veterans. This report explores the contributions of NPs in team-based, population health strategies within the VHA.

METHODS

This review of the literature examines peer-reviewed articles published between 2006 and 2017 to explore the contributions of NPs in team-based, population health strategies within the VHA. Search words include veterans, VHA, NPs, population health, panel management, and chronic disease.

CONCLUSIONS

NPs are vital members of the VHA primary care team; however, there is a dearth of available evidence reflecting the unique contribution of NPs within VHA team-based, population health management strategies.

IMPLICATIONS FOR PRACTICE

The VHA adoption of full practice authority for NP practice provides NPs with an expanded capacity to lead improvements in veterans' health. Future research is needed to fully understand the unique role of the NP in the delivery of population health management strategies for veterans.

Supporting nurse practitioners' practice in primary healthcare settings: a three-level qualitative model

Background

While greater reliance on nurse practitioners in primary healthcare settings can improve service efficiency and accessibility, their integration is not straightforward, challenging existing role definitions of both registered nurses and physicians. Developing adequate support practices is therefore essential in primary healthcare nurse practitioners’ integration. This study’s main objective is to examine different structures and mechanisms put in place to support the development of primary healthcare nurse practitioner’s practice in different healthcare settings, and develop a practical model for identifying and planning adequate support practices.

Methods

This study is part of a larger multicentre study on primary healthcare nurse practitioners in the province of Quebec, Canada. It focuses on three healthcare settings into which one or more primary healthcare nurse practitioners have been integrated. Case studies have been selected to cover a maximum of variations in terms of location, organizational setting, and stages of primary healthcare nurse practitioner integration. Findings are based on the analysis of available documentation in each primary healthcare setting and on semi-structured interviews with key actors in each clinical team. Data were analyzed following thematic and cross-sectional analysis approaches.

Results

This article identifies three types of support practices: clinical, team, and systemic. This three-level analysis demonstrates that, on the ground, primary healthcare nurse practitioner integration is essentially a team-based, multilevel endeavour. Despite the existence of a provincial implementation plan, the three settings adopted very different implementation structures and practices, and different actors were involved at each of the three levels. The results also indicated that nursing departments played a decisive role at all three levels.

Conclusions

Based on these findings, we suggest that support practices should be adapted to each organization’s environment and experience and be modified as needed throughout the integration process. We also stress the importance of combining this approach with a strong coordination mechanism involving managers who have in-depth understanding of nursing professional roles and scopes of practice. Making primary healthcare nurse practitioner integration frameworks more flexible and clarifying and strengthening the role of senior nursing managers could be the key to successful integration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2363-4) contains supplementary material, which is available to authorized users.

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BACKGROUND

Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently.

OBJECTIVES

Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role.

DESIGN

A cross-sectional survey design was used to collect data from primary care NPs.

SETTINGS

The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs.

PARTICIPANTS

807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%.

METHODS

The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery.

RESULTS

About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled.

CONCLUSIONS

NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BACKGROUND

Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness.

OBJECTIVE

To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles.

METHODS

Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel.

RESULTS

The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles.

CONCLUSION

Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.

The Untapped Potential of the Nurse Practitioner Workforce in Reducing Health Disparities

The growing nurse practitioner (NP) workforce represents a significant supply of primary care providers, who if optimally utilized, are well-positioned to improve access to health care for racial and ethnic minorities. However, many barriers affect the optimal utilization of NPs in primary care delivery. These barriers may also prevent NPs from maximally contributing to efforts to reduce racial and ethnic health disparities. Our review of the empirical and health policy literature sought to elucidate factors that affect NPs' potential and ability to narrow or eliminate health disparities. We found that restrictive state scope of practice regulations, disparate reimbursement policies, lack of NP workforce diversity, and poor organizational structures in NP practices may limit NPs' contributions to current efforts to reduce disparities. Our results led to the development of the nurse practitioner health disparities model which identifies barriers to and opportunities for optimal use of NPs in reducing racial and ethnic disparities. State and federal policymakers and administrators in health-care settings should take actions to remove legislative and organizational barriers to enable NPs to deliver high-quality care to racial and ethnic minorities. Researchers can use the nurse practitioner health disparities model to produce empirical evidence to reduce health disparities and improve population health.

A System Approach to Advanced Practice Clinician Standardization and High Reliability

Advanced practice clinicians (APCs) are an integral part of the health care team. Opportunities exist within Advocate Health Care to standardize and optimize APC practice across the system. To enhance the role and talents of APCs, an approach to role definition and optimization of practice and a structured approach to orientation and evaluation are shared. Although in the early stages of development, definition and standardization of accountabilities in a framework to support system changes are transforming the practice of APCs.

The Direct Observation of Nurse Practitioner Care study: An overview of the NP/patient visit

BACKGROUND AND PURPOSE

While there is a preponderance of studies that demonstrate the quality of nurse practitioner (NP) practice, little is known on the practice style of NPs. The Direct Observation of Nurse Practitioner Care study provided the first national direct observation and characterization of patient care delivered by primary care NPs.

METHODS

The setting for this study was ambulatory care practices of NPs located throughout the United States. A nested sample was utilized, consisting of 22 NPs during visits with 245 patients. Observational data were collected during each visit using the Davis observation code (DOC). Patient information was collected from chart reviews and postvisit surveys. Each NP filled out a demographic and practice survey.

CONCLUSIONS

Visits to NPs were 18 min on average, and were most frequently for new/acute problems (45.1%) or routine chronic problems (30.2%). Overall, NPs spent the most time planning treatment, history taking, and providing health education. Topics that NPs frequently provided health education about included medication action and side effects, disease process education, diet, and nutrition.

IMPLICATIONS FOR PRACTICE

Data from this study will allow for detailed characterizations of a patient-NP visit and average length of the visit and the time use based on the DOC.

Considering disparities: How do nurse practitioner regulatory policies, access to care, and health outcomes vary across four states?

BACKGROUND

Health disparities persist among morbidity and mortality rates in the United States. Contributing significantly to these disparities are the ability to pay for health care (largely, access to health insurance) and access to, and capacity of, the primary care health workforce.

PURPOSE

This article examines key determinants of health (DOH) including demographics, public and regulatory policies, health workforce capacity, and primary health outcomes of four states of the United States. The context of this study is the potential association among health care disparities and myriad DOH, among them, the restrictive nurse practitioner (NP) scope of practice (SOP) regulatory environment, which are documented to influence access to care and health outcomes.

METHODS

This descriptive study explores current NP SOP regulations, access to primary care, and health outcomes of key chronic disease indicators-diabetes, hypertension, and obesity in Alabama, Colorado, Mississippi, and Utah. These states represent both the greatest disparity in chronic disease health outcomes (obesity, diabetes, and hypertension) and the greatest difference in modernization of their NP SOP laws. The Affordable Care Act has greatly expanded access to health care. However, it is estimated that 23 million Americans, 7% of its total population, will remain uninsured by 2019.

DISCUSSION

Restrictive and inconsistent NP SOP policies may continue to contribute to health workforce capacity and population health disparities across the country, with particular concern for primary care indicators. The study findings bring into question whether states with more restrictive NP SOP regulations impact access to primary care, which may in turn influence population health outcomes. These findings suggest the need for further research. NPs are essential for meeting the increasing demands of primary care in the United States, and quality-of-care indicator research supports their use.

Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model

BACKGROUND

Nurse practitioners (NPs), if utilized to their optimal potential, could play a key role in meeting the growing demand for primary care.

PURPOSE

The purpose of this study was to propose a comprehensive model for maximizing NP contributions to primary care which includes the factors affecting NP care and patient outcomes and explains their interrelated impact.

METHOD

We synthesized the results of the published literature to develop a model, which emphasizes NP scope of practice regulations, institutional policies, NP practice environment, and NP workforce outcomes as determinants of NP care and patient outcomes.

DISCUSSION

Our model provides a framework to help explain how variations in scope of practice regulations at the state-level and institutional policies within organizations directly and indirectly influence the practice environment of NPs, NP workforce outcomes, and patient care and outcomes.

CONCLUSION

Aligning policy change, organizational innovations, and future research are critical to NP optimal utilization and patient care and outcomes.

Task-Shifting From Physicians to Nurses in Primary Care and its Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Task-shifting from physicians to nurses has gained increasing interest in health policy but little is known about its efficiency. This systematic review was conducted to compare resource utilization with task-shifting from physicians to nurses in primary care. Literature searches yielded 4,589 citations. Twenty studies comprising 13,171 participants met the inclusion criteria. Meta-analyses showed nurses had more return consultations and longer consultations than physicians but were similar in their use of referrals, prescriptions, or investigations. The evidence has limitations, but suggests that the effects may be influenced by the utilization of resources, context of care, available guidance, and supervision. Cost data suggest physician-nurse salary and physician's time spent on supervision and delegation are important components of nurse-led care costs. More rigorous research involving a wider range of nurses from many countries is needed reporting detailed accounts of nurses' roles and competencies, qualifications, training, resources, time available for consultations, and all-cause costs.

Medication adherence in a nurse practitioner managed clinic for indigent patients

PURPOSE

Little is published in the literature about medication adherence rates among patients who are medically indigent and patients receiving primary care from nurse practitioners (NPs). This project examined adherence rates and barriers to adherence among patients at an NP-managed health clinic (NPMC).

DATA SOURCES

The setting for this research was an NPMC for uninsured and low-income patients. A cross-sectional convenience sample of patients (n = 119) completed surveys eliciting demographic information, self-report of medication adherence, health literacy, and barriers to adherence.

CONCLUSIONS

Analysis of subjects demonstrated a vulnerable population, yet the mean adherence rate was surprisingly high (77%), compared to the rate usually cited in published literature. The best predictive model differentiating patients with high adherence from those with low adherence combined the total number of reported barriers, health literacy, and employment status. The barriers most frequently cited by subjects were difficulty paying for medications, and difficulty reading and understanding written prescription labels, which was particularly prevalent among Spanish-speaking patients.

IMPLICATIONS FOR PRACTICE

Clinic efforts to improve patient access to affordable medications may have contributed to subjects' high rates of adherence. These efforts included helping patients with filling out prescription assistance program paperwork, prescribing generic medications, providing samples, and providing effective patient education.