Nurse Practitioners as Attending Providers for Injured Workers: Evaluating the Effect of Role Expansion on Disability and Costs

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Implementation of the Nurse Practitioner as Most Responsible Provider model of care in a Specialised Mental Health setting in Canada

Globally, mental health systems have failed to adequately respond to the growing demands of mental health services resulting in a disparity between the need and provision of treatment. Paucity of mental health care providers contributes to the aforementioned disparity. This can be addressed by engaging Nurse Practitioners (NPs) in an integrated model within healthcare teams. This paper describes the implementation of NPs as Most Responsible Provider (MRP) care of model in a specialised mental health hospital in Ontario, Canada. Guided by the participatory, evidence-based, patient-focused process for advanced practise nursing (APN) role development, implementation, and evaluation (PEPPA) framework, authors developed a model of care and implemented the first seven steps of the PEPPA framework - (a) define the population and describe the current model of care, (b) identify stakeholders, (c) determine the need for a new model of care (d) identify priority areas and goals of improvement, (e) define the new model of care, and (f) plan and implement the NP as MRP model of care. Within these steps, different strategies were implemented: (a) revising policies and procedures (b) harmonising reporting structures, (c) developing and implementing a collaborative practise structure for NPs, (d) standardised and transparent compensation (e) performance standards and monitoring (f) Self-Assessment Competency frameworks, education, and development opportunities. This paper contributes to the state of the knowledge by implementing NPs as MRP model of care in a specialised mental health care setting in Ontario, Canada; and advocates the need for incorporating mental health programmes within the Ontario nursing curriculum.

Mapping first-line health care providers' roles, practices, and impacts on care for workers with compensable musculoskeletal disorders in four jurisdictions: A critical interpretive synthesis

BACKGROUND

First-line health care providers are the primary access point for workers' benefits. However, little is known about their impact on quality of care and return-to-work. Our objective was to critically compare literature on the practices of first-line providers for workers with musculoskeletal injuries in Ontario and Quebec (Canada), Washington State (United States), and Victoria (Australia).

METHODS

A critical interpretive synthesis of peer-reviewed scientific literature was conducted. The search across six databases yielded 59 relevant publications that were critically appraised.

RESULTS

Three themes emerged: 1) how policies about first-line health care providers' modulate worker access to care, 2) how these providers' roles, practices, and training shape disability management, and 3) how the quality of care and disability outcomes are evaluated.

CONCLUSIONS

First-line health care providers have a critical influence on workers' trajectories of care. A focus on their role while taking the complexity of the context into account will help orient future policy changes.

An Integrated Nurse Practitioner-Run Subspecialty Referral Program for Incontinent Children

INTRODUCTION

Evidence suggests that urinary and fecal incontinence and abnormal voiding and defecation dynamics are different manifestations of the same syndrome. This article reports the success of an innovative program for care of children with incontinence and dysfunctional elimination. This program is innovative because it is the first to combine subspecialty services (urology, gastroenterology, and psychiatry) in a single point of care for this population and the first reported independent nurse practitioner-run specialty referral practice in a free-standing pediatric ambulatory subspecialty setting. Currently, services for affected children are siloed in the aforementioned subspecialties, fragmenting care.

METHODS

Retrospective data on financial, patient satisfaction, and patient referral base were compiled to assess this program.

RESULTS

Analysis indicates that this model is fiscally sound, has similar or higher patient satisfaction scores when measured against physician-run subspecialty clinics, and has an extensive geographic referral base in the absence of marketing.

DISCUSSION

This model has potential transformative significance: (a) the impact of children achieving continence cannot be underestimated, (b) configuration of services that cross traditional subspecialty boundaries may have broader application to other populations, and (c) demonstration of effectiveness of non-physician provider reconfiguration of health care delivery in subspecialty practice may extend to the care of other populations.

Which Characteristics are Associated with the Timing of the First Healthcare Consultation, and Does the Time to Care Influence the Duration of Compensation for Occupational Back Pain?

Purpose To identify the characteristics associated with the timing of the first healthcare consultation and to measure the impact of that timing on the duration of the first episode of compensation for occupational back pain following the injury. Methods We analyzed data from a cohort of workers with compensated back pain in 2005 in Ontario obtained from the Workplace Safety and Insurance Board. Cox multivariable survival models were performed to identify factors associated with the time to care and to measure its association with the length of the first episode of 100 % compensation. Results Among the 5520 claims analyzed, 93.7 % of workers accessed care within the first week (average = 2.1 days; median = 1 day). Time to care was shorter for males, for workers who had received previous compensation and for those with access to an early return to work program. Age, number of employees in the company and personal earnings were positively associated with the time to care. More severe nature of injury, employers doubt about the work-relatedness of the injury and consulting a physiotherapist as the first healthcare provider were also associated with longer time to care. Considering potential confounders, longer time to care was significantly associated with a delay in the end of the first episode of compensation (hazard ratio = 0.98; P < 0.001). Conclusion Temporal access to a source of care is not problematic for the vast majority of Ontarian workers who receive compensation for occupational back pain; however, for the minority of workers who do not rapidly access care, the timing of the first healthcare consultation is a significant predictor of the duration of the first episode of compensation.

Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain

Objective To compare the duration of financial compensation and the occurrence of a second episode of compensation of workers with occupational back pain who first sought three types of healthcare providers. Methods We analyzed data from a cohort of 5511 workers who received compensation from the Workplace Safety and Insurance Board for back pain in 2005. Multivariable Cox models controlling for relevant covariables were performed to compare the duration of financial compensation for the patients of each of the three types of first healthcare providers. Logistic regression was used to compare the occurrence of a second episode of compensation over the 2-year follow-up period. Results Compared with the workers who first saw a physician (reference), those who first saw a chiropractor experienced shorter first episodes of 100 % wage compensation (adjusted hazard ratio [HR] = 1.20 [1.10-1.31], P value < 0.001), and the workers who first saw a physiotherapist experienced a longer episode of 100 % compensation (adjusted HR = 0.84 [0.71-0.98], P value = 0.028) during the first 149 days of compensation. The odds of having a second episode of financial compensation were higher among the workers who first consulted a physiotherapist (OR = 1.49 [1.02-2.19], P value = 0.040) rather than a physician (reference). Conclusion The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.

Nurse Practitioners' Comfort in Treating Work-Related Injuries in Adolescents

This study examined nurse practitioners' (NPs) previous experiences and comfort levels in treating adolescents with work-related injuries in two states where NPs have statutory authority to treat work-related injuries. The authors surveyed all actively licensed NPs in Washington and Oregon (N = 4,849). Factors associated with NPs' previous experiences and comfort in treating adolescents with work-related injuries were identified using modified Poisson regression. Less than a quarter of respondents (21.1%, n = 225) reported having ever treated an adolescent for a work-related injury. Nearly half (43.6%) of respondents reported being uncomfortable or very uncomfortable in treating adolescents with work-related injuries. Previous experience and male gender were associated with greater likelihood of feeling comfortable (p < .01). Nurse practitioners serve as primary care providers for adolescents who may experience work-related injuries. This study documents the need for developing educational and outreach efforts to better prepare NPs to treat adolescents' work-related injuries.

Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians

OBJECTIVE

This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs).

DATA SOURCE

Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010.

STUDY DESIGN

Retrospective cohort design using propensity score weighted regression.

DATA EXTRACTION METHODS

Beneficiaries cared for by a random sample of NPs and primary care physicians.

PRINCIPAL FINDINGS

After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well.

CONCLUSIONS

This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.

The Occupational Health Nurse as the Trusted Clinician in the 21st Century

Occupational health nurses as trusted clinicians use their direct care skills in both on-site and off-site roles to protect human resources and contain health care costs. On-site clinics leverage the knowledge, skills, and abilities of occupational health nurses. To maximize the health of the work force, occupational health nurses use strategies aimed at improving health, engaging employees, enhancing accountability of employees, linking provider strategies, using technology creatively, and promoting healthy work environments. Occupational health nurses maintain a proactive and effective impact on occupational health and safety as part of a broader framework of holistic primary care.

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.

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.

Including injured workers without compensated time loss in Cox regression models: analyzing time loss using all available data

INTRODUCTION

Cox proportional hazards regression is commonly used to analyze time loss duration, but statistical packages conventionally exclude cases with no recorded follow-up time. For this and other substantive reasons, many researchers limit time loss analyses to the subset of workers who received time loss compensation. This can exclude both injured workers who missed no work days and those missing up to a week of work. For some research questions, excluding cases where injury is reported but no time loss is recorded may result in significant ascertainment bias. We present a novel technique based on standard survival analysis methods to allow for the inclusion of all cases when appropriate.

METHODS

A simple technique to allow standard statistical software to include both medical-only and time loss claims in Cox regression is illustrated by example and compared with a two-part model using a time-varying step function to allow regression effects to change over time.

RESULTS

We showed that a pooled analysis is obtained by simply adding a small constant to the time loss duration variable. This technique produced appropriate estimates while accounting for censoring when a suitable method was used for tied event times. Using a formal statistical framework, the combined model was justified as a special case of the more standard two-part model approach.

CONCLUSIONS

When it is desirable to have a single pooled outcome estimate for injured workers with both medical-only and time loss claims, all claims can be combined into one statistical model. This may have particular utility for research questions where the risk factor or intervention of interest would be expected to affect time loss duration beginning upstream of claim filing or statutory compensation waiting periods. This novel alternative modeling strategy expands the tool kit available for analyzing time loss data.

Expanding the role of nurse practitioners: effects on rural access to care for injured workers

CONTEXT

A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician.

PURPOSE

The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing.

METHODS

Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group.

FINDINGS

NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas.

CONCLUSIONS

Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.