Medication adherence, costs, and ER visits of nurse practitioner and primary care physician patients: Evidence from three cohorts of Medicare beneficiaries

The Future of Psychiatric-Mental Health Nursing: Observe, Reflect, and Take Action to Empower Knowledge for the Greater Good

The purpose of this article is a call for action to identify areas of concern and promise for the specialty of psychiatric-mental health nursing to flourish in the twenty first century and beyond in the United States. Bits and pieces of this call for action may be relevant to other countries where psychiatric-mental health nursing has had similar trends. However, this paper focuses on the issues, barriers, and politics of education, practice, and research for nurses in the United States who gravitate to psychiatric-mental health and endeavor to rise above the value-laden past that perpetuates the marginalization of not only the specialty, but also the work that PMHN do and for the individuals that they are meant to care for in the new millennial. Much of the history of PMHN knowledge and care is value-laden, biased and riddled in patriarchy, fundamental religious views from centuries ago, and a basic fear of the unknown. It is well over due to sort through the closets and filing cabinets of the specialty's knowledge to clear out the stigma, the myths, the unknown and the "doctor knows best" world view. If PMHN is to survive and truly heal or comfort the suffering that is observed and witnessed first-hand in the twenty first century, a deliberate and purposeful approach is needed.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Comparison of Ambulatory Quality Measures Between Shared Practice Panels and Independent Practice Panels

Objective

To assess for differences in patient care outcomes in the primary care setting for patients assigned to an independent practice panel (IPP) or a shared practice panel (SPP).

Patients and Methods

We retrospectively reviewed the electronic health records of patients of 2 Mayo Clinic family medicine primary care clinics from January 1, 2019 to December 31, 2019. Patients were assigned to either an IPP (physician or advanced practice provider [APP]) or an SPP (physician and ≥1 APP). We assessed 6 measures of quality care and compared them between IPP and SPP groups: diabetes optimal care, hypertension control, depression remission at 6 months, breast cancer screening, cervical cancer screening, and colon cancer screening.

Results

The study included 114,438 patients assigned to 140 family medicine panels during the study period: 87 IPPs and 53 SPPs. The IPP clinicians showed improved quality metrics compared with the SPP clinicians for the percentage of assigned patients achieving depression remission (16.6% vs 11.1%; P<.01). The SPP clinicians showed improved quality metrics compared with that of the IPP clinicians for the percentage of patients with cervical cancer screening (79.1% vs 74.2%; P<.01). The mean percentage of the panels achieving optimal diabetes control, hypertension control, colon cancer screening, and breast cancer screening were not significantly different between IPP and SPP panels.

Conclusion

This study shows a considerable improvement in depression remission among IPP panels and in cervical cancer screening rates among SPP panels. This information may help to inform primary care team configuration.

Association between hospital-physician vertical integration and medication adherence rates

OBJECTIVE

To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins.

DATA SOURCES

Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017.

STUDY DESIGN

We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity.

EXTRACTION METHODS

We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period.

PRINCIPAL FINDINGS

The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes.

CONCLUSIONS

While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.

The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.

Hospitalizations for Ambulatory Care Sensitive Conditions in a Large City of Japan: a Descriptive Analysis Using Claims Data

BACKGROUND

Hospitalization for ambulatory care sensitive conditions (ACSCs) is an indicator of the quality of primary care in different health systems. In Japan, where patients can choose any healthcare facility with universal health coverage (UHC), data on these admissions are unknown.

OBJECTIVE

To describe the current situation of ACSC admissions in a city of Japan.

DESIGN

Retrospective observational study using claims data.

PARTICIPANTS

Beneficiaries aged 0-74 years of the National Health Insurance (NHI) program in a large city in the Greater Tokyo Area. We extracted ACSC admissions from all inpatient claims between April 2013 and March 2017.

MAIN MEASURES

We calculated age- and sex-specific annual ACSC admission rates for three categories: acute, chronic, and vaccine-preventable. We estimated the age-adjusted admission rates by ACSC category according to administrative districts and rate ratios using Poisson regression models. We also estimated medical expenditures and lengths of stay for ACSC admissions.

KEY RESULTS

Of 91,350 hospitalization episodes, we identified 7666 (8.4%) that were ACSC admissions. Males had higher annual ACSC admission rates than females (p < 0.001), especially for chronic ACSCs. Admission rates were lowest in those aged 15-39 years and higher in the youngest (0-4 years) and oldest (70-74 years) age groups. Age-adjusted chronic ACSC admission rates were lower in a newly developed area (rate ratio [RR]: 0.79, 95% confidence interval [CI]: 0.71-0.87) and higher in a residential area (RR: 1.14, 95% CI: 1.04-1.24) than in the center of the city. Total medical expenditures for all ACSC admissions accounted for 5.8% of the total inpatient expenditures of NHI in the city.

CONCLUSIONS

ACSC admission rates in Japan were higher for males than for females and showed a U-shaped trend in terms of age, as in other countries with UHC, and deferred by region. This study provided possible factors to reduce ACSC admissions.

Supply-side solutions targeting demand-side characteristics: causal effects of a chronic disease management program on adherence and health outcomes

We estimate the effects of a chronic disease management program (CDMP) which adapts various supply-side interventions to specific demand-side conditions (disease-staging) for patients with chronic kidney disease (CKD). Using a unique dataset on the entire population of the Emilia-Romagna region of Italy with hospital-diagnosed CKD, we estimate the causal effects of the CDMP on adherence indicators and health outcomes. As CKD is a progressive disease with clearly-defined disease stages and a treatment regimen that can be titrated by disease severity, we calculate dynamic, severity-specific, indicators of adherence as well as several long-term health outcomes. Our empirical work produces statistically significant and sizeable causal effects on many adherence and health outcome indicators across all CKD patients. More interestingly, we show that the CDMP produces larger effects on patients with early-stage CKD, which is at odds with some of the literature on CDMP that advocates intensifying interventions for high-cost (or late-stage) patients. Our results suggest that it may be more efficient to target early-stage patients to slow the deterioration of their health capital. The results contribute to a small, recent literature in health economics that focuses on the marginal effectiveness of CDMPs after controlling either for supply- or demand-side sources of heterogeneity.

Feasibility and acceptability of the community-based program: Plan Ahead

OBJECTIVES

In this article, we assess the feasibility and acceptability and the effect of the Plan Ahead for community dwelling older adults. In addition, we investigated the effects of the program. In addition, we aimed to examine whether the completion of the specific Future Care Planning depended on the participants' competence level.

METHODS

In this single group feasibility study, trained facilitators delivered the program to a sample of 234 community-residing older adults. Participants completed both pre, post assessments about the acceptability of the program and their completion of the recommended future care planning activities.

RESULTS

Based on participant's report on the usefulness and satisfaction of the program after the completion of the program, we found that participants reported high levels of acceptance of the program. Participation rates also confirmed the feasibility of the program. In terms of effects of program implementation, statistically significant changes were noted for several outcomes, such as resource building and FCP activities. In particular, we found that these gains were particularly robust for participants in the low competence group.

CONCLUSION

Pilot program results suggest the feasibility of a short community program enhancing proactive planning for future care needs among older adults residing in their community.

Recruitment and retention of primary care nurse practitioners in underserved areas: A scoping review

BACKGROUND

The growing nurse practitioner (NP) workforce plays a critical role in primary care delivery in the United States. However, better recruitment and retention of the robust NP workforce in underserved areas are needed; evidence to inform such effort is limited.

PURPOSE

This scoping review aimed to examine the findings, scope, and knowledge gaps of available literature on factors associated with NP recruitment and retention in underserved areas.

METHODS

This review was guided by Joanna Briggs' Scoping Review Methodology and PRISMA-SCR reporting standards. Literature search for peer-reviewed and gray literature was conducted in six databases.

FINDINGS

A total of 22 studies met inclusion criteria. Factors associated with NP recruitment and retention in underserved areas were mapped into five themes, including factors related to: the individual NP, NP education programs/financial aid, organizations employing NPs, the communities NPs work in, and autonomous practice. Majority of the included studies were published before 2010; few used rigorous study designs and analysis methods; and few exclusively studied NPs and unique challenges facing the NP workforce.

DISCUSSION

Available studies demonstrate that NP recruitment and retention can be addressed by various stakeholders (e.g., educators, policy makers); however, up-to-date, methodologically rigorous, and NP-focused studies are needed.

Nurse practitioner-owned practices and value-based payment

BACKGROUND

The United States is steadily shifting away from volume-based payments toward value-based payment for health care. The nursing model's emphasis on high-value care, such as disease prevention and health maintenance, ideally positions nurse practitioner (NP) practice owners to contribute to the goals of value-based care. However, little is known about NP participation in value-based care.

PURPOSE

To better understand NP-owned practice participation in value-based care.

METHODOLOGY

Using convenience sampling, we developed a registry of NP owned practices, which we used to conduct a web-based survey from November 2019 to February 2020.

RESULTS

Of the 47 NP-owner respondents, 40 practice in primary or specialty care. Practices are relatively small with a mean clinical staff of 4 full-time equivalent (FTE; range: 1-17), mean total staff of 7 FTE (1-28.5), and with a mean of 325 patient visits annually. A third participate in value-based payment arrangements, whereas a half are considering and three quarters are knowledgeable about value-based payment arrangements. Over 70% of practice owners report lack of knowledge, lack of financial protections, and lack of payer partnership as barriers to participation in value-based payment models.

CONCLUSIONS

NP practice owners face many challenges to taking on risk, including insufficient patient volume.

IMPLICATIONS

Joining together may allow small NP practices to participate in and thrive under value-based payment. Reducing the barriers and regulation of all NPs will enable the health care system to capitalize on the nursing model to meet the goals of value-based care.

Treatment Adherence in Integrative Medicine-Part One: Review of Literature

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care

OBJECTIVE

This study sought to assess whether patients with autoimmune disease would accept advanced practice providers (APPs) as an option to fill the growing shortage of rheumatologists.

METHODS

We administered a cross-sectional survey to 500 patients or parents of children who reported having been diagnosed with qualifying autoimmune conditions and who had seen their primary rheumatology providers in the past 6 months. Respondents self-reported whether their primary providers were rheumatologists or APPs. Our analysis compared the attitude and experience of the patients whose primary rheumatology providers were APPs with those of patients whose primary providers were rheumatologists.

RESULTS

Of respondents, 36.8% reported having APPs as primary rheumatology providers. Patients of APPs were significantly more likely to arrive at their provider's office in 15 minutes or less (p < 0.01) and to be able to schedule routine and urgent appointments sooner (p = 0.02, 0.05). There were no significant differences for overall patient experience of care between provider types. Most patients rated their providers highly, but those who saw rheumatologists rated their providers significantly higher (p < 0.01). APP patients were significantly more likely than rheumatologist patients to prefer to see APPs over rheumatologists (p < 0.01) and to recommend APPs (p < 0.01).

CONCLUSIONS

APPs may improve access to care, and regardless of provider type, patients rated their overall experience of care similarly. Overall, patient attitudes toward APPs were positive regardless of provider type, although APP patients held more positive overall attitudes toward APPs than did rheumatologist patients.

Potentially inappropriate medication prescribing by nurse practitioners and physicians

BACKGROUND

Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.

OBJECTIVE

We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.

RESEARCH DESIGN

We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.

RESULTS

There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.

CONCLUSIONS

NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.

Methodology for a six-state survey of primary care nurse practitioners

BACKGROUND

Primary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations.

PURPOSE

In this paper, we report the methods of the largest survey of primary care NPs to date.

METHODS

To overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments.

FINDINGS

While we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty.

DISCUSSION

In future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries

BACKGROUND

Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences.

RESEARCH OBJECTIVE

Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs).

STUDY DESIGN

Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata.

RESULTS

Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs.

CONCLUSIONS

There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care

BACKGROUND

Nonadherence to medications is costly and improving adherence is difficult, requiring multifactorial solutions, including policy solutions.

OBJECTIVE

The purpose of this study is to evaluate the effect of one policy strategy on medication adherence. Specifically, we examine the effect on adherence of expanding scope-of-practice regulations for nurse practitioners (NPs) to practice and prescribe without physician supervision.

DESIGN

We conducted three difference-in-difference multivariable analyses of commercial insurance claims.

PARTICIPANTS

Patients who filled at least two prescriptions in one of three chronic therapeutic medications: anti-diabetics (n = 514,255), renin angiotensin system antagonists (RASA) (n = 1,679,957), and anti-lipidemics (n = 1,613,692).

MAIN MEASURES

Medication adherence was measured as the proportion of days covered (PDC). We used one continuous (PDC 0-1) and one binary outcome (PDC of > .8), the latter indicating good adherence.

KEY RESULTS

Patients taking anti-diabetic medications had a 1.9 percentage point higher medication adherence rate (p < 0.05) and a 2.7 percentage point higher probability of good adherence (p < 0.001) in states that expanded NP scope-of-practice. Medication adherence for patients taking RASA was higher by 2.3 percentage points (p < 0.001) and 3.4 percentage points (p < 0.01) for both measures, respectively. Patients taking anti-lipidemics saw a smaller, but statistically insignificant, improvement in adherence.

CONCLUSIONS

Results indicate that scope-of-practice regulations that allow NPs to practice and prescribe without physician oversight are associated with improved medication adherence. We postulate that the mechanism for this effect is increased access to health care services, which in turn increases access to prescriptions. Our results suggest that policies allowing NPs to maximally use their skills can be beneficial to patients.

Subsidizing access to prescription drugs and health outcomes: The case of diabetes

This paper evaluates the health effects of a large-scale subsidizing program of prescription drugs introduced in Brazil, the Aqui Tem Farmácia Popular program (ATFP). We exploit features of the program to identify its effects on mortality and hospitalization rates by diabetes for individuals aged 40 years or more. We find weak evidence for a decline in mortality, but a robust reduction in hospitalization rates. According to our preferred specification, an additional ATFP pharmacy per 100,000 inhabitants is associated with a decrease in hospitalization rates by diabetes of 8.2, which corresponds to 3.6% of its baseline rate. Effects are larger for Type II diabetes in comparison to Type I, and among patients with relatively lower socioeconomic status. Overall, the results are consistent with insulin-dependent patients being relatively less responsive to subsidies because of higher immediate life-threatening risks; and with lower-SES individuals being more responsive because of liquidity constraints. These results support the view that the optimal design of health systems and cost-sharing mechanisms should take into account equity concerns, heterogeneous impacts by health condition, and their potential offsetting effects on the utilization of downstream health services.

Examining variable nurse practitioner independence across jurisdictions: A case study of the United States

BACKGROUND

Nurse Practitioners have the potential to reduce primary care shortages for underserved populations. Yet, scopes of practice in some political jurisdictions (e.g. states, provinces) are more restrictive than others, and prevent Nurse Practitioners from working to the full extent of their training. The research is limited as to which intrastate or interstate characteristics contribute to understanding why scope of practice differences exist.

OBJECTIVES

To estimate associations between intrastate/interstate characteristics and US state-level Nurse Practitioner Scope of Practice policy.

RESEARCH DESIGN

Retrospective study of state-level factors influencing Nurse Practitioner Scopes of Practice.

SUBJECTS

U.S. states from 2001 to 2015.

MEASURES

Our dependent variable is state-level Scope of Practice policy, indicating the extent to which Nurse Practitioners are autonomous in a state (Independent, Collaboration or Supervision). The intrastate characteristics that we include are numbers of Nurse Practitioners, Primary Care Physicians and rural hospitals per capita, state Board of Medicine governance and Nursing License Compact membership. We also measure the number of border-states that adopt specific policies in order to indicate the extent to which interstate characteristics influence focal states to adopt similar policies.

RESULTS

Among intrastate characteristics, we found that rural hospital concentrations (Odds Ratio=0.78; 95% Confidence Interval: 0.71-0.85) and Nursing License Compact membership (Odds Ratio=0.23; 95% Confidence Interval: 0.0-0.60) were associated with lower levels of restrictions, while Board of Medicine governance (Odds Ratio=27.36; 95% Confidence Interval: 5.75-130.20) was associated with increased levels of restrictions. Among interstate characteristics, higher numbers of border-states adopting Nursing License Compact membership (Odds Ratio=0.51; 95% Confidence Interval: 0.32-0.80) was associated with lower levels of restrictions.

CONCLUSIONS

Barriers to Nurse Practitioner independence are largely attributable to unfavorable governance arrangements and non-participation in reciprocal licensing networks. Achieving Nurse Practitioner independence will require cooperation between nursing, medicine and policy makers. We offer some suggestions as to where parties interested in seeing increased Nurse Practitioner independence should focus their efforts when attempting to remove restrictions on Nurse Practitioner practice.

Frequent general practitioner visits are protective against statin discontinuation after a Pharmaceutical Benefits Scheme copayment increase

Objective This study assessed the effect of the frequency of general practitioner (GP) visitation in the 12 months before a 21% consumer copayment increase in the Pharmaceutical Benefits Scheme (PBS; January 2005) on the reduction or discontinuation of statin dispensing for tertiary prevention. Methods The study used routinely collected, whole-population linked PBS, Medicare, mortality and hospital data from Western Australia. From 2004 to 2005, individuals were classified as having discontinued, reduced or continued their use of statins in the first six months of 2005 following the 21% consumer copayment increase on 1 January 2005. The frequency of GP visits was calculated in 2004 from Medicare data. Multivariate logistic regression models were used to determine the association between GP visits and statin use following the copayment increase. Results In December 2004, there were 22495 stable statin users for tertiary prevention of prior coronary heart disease, prior stroke or prior coronary artery revascularisation procedure. Following the copayment increase, patients either discontinued (3%), reduced (12%) or continued (85%) their statins. Individuals who visited a GP three or more times in 2004 were 47% less likely to discontinue their statins in 2005 than people attending only once. Subgroup analysis showed the effect was apparent in men, and long-term or new statin users. The frequency of GP visits did not affect the proportion of patients reducing their statin therapy. Conclusions Patients who visited their GP at least three times per year had a lower risk of ceasing their statins in the year following the copayment increase. GPs can help patients maintain treatment following rises in medicines costs. What is known about the topic? Following the 21% increase in medication copayment in 2005, individuals discontinued or reduced their statin usage, including for tertiary prevention. What does this paper add? Patients who visited their GP at least three times per year were less likely to discontinue their statin therapy for tertiary prevention following a large copayment increase. What are the implications for practitioners? This paper identifies the important role that GPs have in maintaining the continued use of important medications following rises in medicines costs.

Differences in hospitalizations, emergency room admissions, and outpatient visits among Mexican-American Medicare beneficiaries

BACKGROUND

Few studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization.

METHODS

Data came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits.

RESULTS

The percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12-12.59%, 14.15-19.03%, and 76.61-80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21-1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57-0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14-2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43-2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56-0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79-7.89) and ER admissions (OR = 3.63, 95% CI = 2.88-4.57) than participants who survived at least three-years.

CONCLUSION

We observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

Medication adherence, costs, and ER visits of nurse practitioner and primary care physician patients: Evidence from three cohorts of Medicare beneficiaries

OBJECTIVE

To compare medication adherence, cost, and utilization in Medicare beneficiaries attributed to nurse practitioners (NP) and primary care physicians (PCP).

DATA

Medicare Part A, B, and D claims and beneficiary summary file data, years 2009-2013.

STUDY DESIGN

We used propensity score-weighted analyses combined with logistic regression and generalized estimating equations to test differences in good medication adherence (proportion of days covered (PDC >0.8); office-based and specialty care costs; and ER visits.

DATA EXTRACTION

Beneficiaries with prescription claims for anti-diabetics, renin-angiotensin system antagonists (RASA), or statins.

PRINCIPAL FINDINGS

There were no differences in good medication adherence (PDC >0.8) between NP and PCP attributed beneficiaries taking anti-diabetics or RASA. Beneficiaries taking statins had a slightly higher probability of good adherence when attributed to PCPs (74.6% vs 75.5%; P < 0.05). NP attributed beneficiaries had lower office-based and specialty care costs and were less likely to experience an ER visit across all three medication cohorts (P < 0.01).

CONCLUSIONS

Examining the impact of NP and PCP provided care on outcomes beyond the primary care setting is important to the Medicare program in general but will also help practices seeking to meet benchmarks under alternative payment models that incentivize higher quality and lower costs.