Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care

Continued restrictions on nurse practitioners: A qualitative study of the early implementation of full practice authority in Massachusetts

BACKGROUND

In January 2021, the Commonwealth of Massachusetts granted nurse practitioners (NPs) full practice authority (FPA). Little is known about how care delivery changed after FPA legislation.

PURPOSE

To understand the NP perception of early implementation of FPA in Massachusetts.

METHODS

Qualitative descriptive design using inductive thematic analysis of open-ended responses to a web-based survey of NPs in Massachusetts from October to December 2021.

FINDINGS

Survey response rate was 50.3% (N = 144). Inductive thematic analysis of open-ended responses identified four themes, including: (a) internal and external barriers obstructed FPA implementation, (b) employer communication about scope-of-practice changes was minimal, (c) NPs led initiatives to implement FPA, and (d) some efforts effectively implemented FPA.

DISCUSSION

Almost 1 year after FPA was passed, external policies persisted that financially incentivized employers to not change NP scope-of-practice. Concerted efforts are needed to ensure that federal and payer policies, such as incident-to billing, are aligned with state law to encourage the implementation of FPA.

Changes in location and number of nurse consultations as the supply of general practitioners decreases in primary health care: six-year register-based follow-up cohort study in the city of Vantaa, Finland

OBJECTIVE

To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations.

DESIGN

A retrospective register-based follow-up cohort study.

SETTING

Public primary health care in the City of Vantaa, Finland.

SUBJECTS

All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014.

MAIN OUTCOME MEASURES

Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department.

RESULTS

Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3-1.7) to 10.5 (10.3-12.2) (p < 0.001) and registered nurse consultations from a median of 3.6 (3.0-4.0) to 14.5 (13.0-16.6) (p < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses.

CONCLUSIONS

It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care.

Evaluating the cost of NP-led vs. GP-led primary care in British Columbia

In 2020, British Columbia (BC) opened four pilot Nurse Practitioner Primary Care Clinics (NP-PCCs) to improve primary care access. The aim of this economic evaluation is to compare the average cost of care provided by Nurse Practitioners (NPs) working in BC's NP-PCCs to what it would have cost the government to have physicians provide equivalent care. Comparisons were made to both the Fee-For-Service (FFS) model and BC's new Longitudinal Family Physician (LFP) model. The analyses relied on administrative data, mostly from the Medical Services Plan (MSP) and Chronic Disease Registry (CDR) via BC's Health Data Platform. Results show the cost of NPs providing care in the NP-PCCs is slightly lower than what it would cost to provide similar care in medical clinics staffed by physicians paid through the LFP model. This suggests that the NP-PCC model is an efficient approach to increase accessibility to primary care services in BC and should be considered for expansion across the province.

A case for the health welfare of Texans-A nurse practitioner state regulation policy analysis

ABSTRACT

Restrictive nurse practitioner (NP) practice regulation at the state level continues to obstruct patient access to quality affordable care because primary care provider shortages heighten across the nation. Evidence-based research supports NPs as cost-effective providers without conceding quality of care. A patchwork of highly variable state policies subjectively determines the degree of collaborative oversight required for NPs to practice in each state. An objective review of policies influencing NP capacity to deliver care promotes evidence-informed policy adaptation. A policy analysis was completed using Bardach and Patashnik's framework to evaluate policy options for NP practice regulation in Texas. Full practice authority (FPA) policy effect was quantitively evaluated through difference-in-differences regression models using selected measures of all 50 states and the District of Columbia. Health welfare outcomes were calculated using emergency department utilization, average household health expenditures, poor physical health days, and NP-specific adverse action reports (AAR). Overall, FPA policy did not have a statistically significant effect on state-clustered emergency department utilization, average household health expenditures, or poor physical health days. Full practice authority was associated with decreased NP AAR. The analysis supports FPA as a viable policy option for states such as Texas and counters claims FPA policy adoption results in detrimental sequalae in the health of the population.

Advanced Practice Registered Nurse Full Practice Authority, Provider Supply, and Health Outcomes: A Border Analysis

Due to a growing physician shortage, patients have difficulty accessing primary care. In an effort to expand access and support patient health, many states are reducing barriers for advanced practice registered nurses to provide primary care without physician collaboration. Maryland provides an interesting case study. We leverage Maryland's policy change to explore the effects of full practice authority (FPA), focusing on the number of professionals and health outcomes for patients. Employing a border county comparison between Maryland and Pennsylvania, we estimate the effect of FPA. Our analysis of health outcomes focuses on three county-level health outcomes: poor or fair health, poor mental health days, and preventable hospital stays. We find that FPA is associated with increases in the number of certified nurse midwives by 0.6 per 100,000 residents and nurse practitioners by 22.4 per 100,000 residents. We also find evidence of an association of FPA with reductions in the share of residents who report being in poor or fair health by 2.8 percentage points and poor mental health days per month by 0.354 days per person. Combined, our results provide suggestive evidence that moving to FPA improves access to care and leads to improved health outcomes for Maryland residents. Removing regulatory barriers that prevent certified nurse midwives and nurse practitioners from working to the full extent of their training may increase access to primary care and improve patient outcomes.

Operationalization of Clinical Placements in Graduate Nursing

BACKGROUND

Nurse practitioner (NP) program accreditation standards require that programs secure clinical placements for all students. As NP programs increase enrollment to meet the demand for primary care providers, it is vital that they deploy a formalized clinical placement process that ensures all students have a clinical placement.

PROBLEM

Although NP programs have consistently increased enrollment, the shortage of clinical sites and preceptors continues to be a barrier to admission.

APPROACH

Described in this article is the operationalization of graduate nursing clinical placement at one large university with 7 NP tracks.

OUTCOMES

A formalized clinical placement process ensures that all students receive an appropriate placement and graduate on time. Having a dedicated team of NP faculty members to provide clinical placements services for NP students is highly effective.

Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD

BACKGROUND

Early interventions in CKD have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain.

METHODS

In this propensity score-matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for ( 1 ) nurse practitioner care versus primary care alone and ( 2 ) nurse practitioner versus nephrologist care. Processes of care were measured within 1 year after cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score-matched groups.

RESULTS

A total of 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (82% versus 79%; absolute differences [ADs] 3.4% [95% confidence interval, 0.0% to 6.9%]) and statins (75% versus 66%; AD 9.7% [5.8% to 13.6%]), fewer prescriptions of nonsteroidal anti-inflammatory drugs (10% versus 17%; AD -7.2% [-10.4% to -4.2%]), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3; rate difference -9.2 [-14.7 to -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0; rate difference -2.7 [-3.6 to -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins, with no difference in the risks of experiencing adverse clinical outcomes.

CONCLUSIONS

Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone and similar to those with care by nephrologists.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_08_CJN0000000000000305.mp3.

Frontline perspectives on adoption and non-adoption of care management tools for high-risk patients in primary care

BACKGROUND

Population health management tools (PHMTs) embedded within electronic health records (EHR) could improve management of high-risk patients and reduce costs associated with potentially avoidable emergency department visits or hospitalizations. Adoption of PHMTs across the Veterans Health Administration (VA) has been variable and previous research suggests that understaffed primary care (PC) teams might not be using the tools.

METHODS

We conducted a retrospective content analysis of open-text responses (n = 1804) from the VA's 2018 national primary care personnel survey to, 1) identify system-level and individual-level factors associated with why clinicians are not using the tools, and 2) to document clinicians' recommendations to improve tool adoption.

RESULTS

We found three themes pertaining to low adoption and/or tool use: 1) IT burden and administrative tasks (e.g., manually mailing letters to patients), 2) staffing shortages (e.g., nurses covering multiple teams), and 3) no training or difficulty using the tools (e.g., not knowing how to access the tools or use the data). Frontline clinician recommendations included automating some tasks, reconfiguring team roles to shift administrative work away from providers and nurses, consolidating PHMTs into a centralized, easily accessible repository, and providing training.

CONCLUSIONS

Healthcare system-level factors (staffing) and individual-level factors (lack of training) can limit adoption of PHMTs that could be useful for reducing costs and improving patient outcomes. Future research, including qualitative interviews with clinicians who use/don't use the tools, could help develop interventions to address barriers to adoption.

IMPLICATIONS

Shifting more administrative tasks to clerical staff would free up clinician time for population health management but may not be possible for understaffed PC teams. Additionally, healthcare systems may be able to increase PHMT use by making them more easily accessible through the electronic health record and providing training in their use.

A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants

BACKGROUND

Physicians see most emergency department (ED) patients, but, recently, nurse practitioners (NPs) and physician assistants (PAs) have provided an increasing amount of ED care.

PURPOSE

Compare NP and PA teams' practice patterns to physician teams in EDs.

METHODS

Using 12 years of data from the National Hospital Ambulatory Medical Care Survey (2009-2020), we used multivariate regression analysis to separately examine the associations between the ED practice patterns (i.e., number of diagnostic services, number of procedures, waiting time, boarding time, length of visit, and hospital admission) of patients seen by NP or PA teams compared with physician teams.

DISCUSSION

Patient visits to NP and PA teams received fewer diagnostic services and procedures, had shorter visits, and were less likely to be hospitalized.

CONCLUSION

If the additional diagnostic services, procedures, and hospital admission provided by physician teams were unnecessary for the patients studied, NP and PA team care could be more efficient.

Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience

OBJECTIVE

This study aims to evaluate the impact of a primary care nurse practitioner (NP)-led clinic model piloted in British Columbia (Canada) on patients' health and care experience.

DESIGN

The study relies on a quasi-experimental longitudinal design based on a pre-and-post survey of patients receiving care in NP-led clinics. The prerostering survey (T0) was focused on patients' health status and care experiences preceding being rostered to the NP clinic. One year later, patients were asked to complete a similar survey (T1) focused on the care experiences with the NP clinic.

SETTING

To solve recurring problems related to poor primary care accessibility, British Columbia opened four pilot NP-led clinics in 2020. Each clinic has the equivalent of approximately six full-time NPs, four other clinicians plus support staff. Clinics are located in four cities ranging from urban to suburban.

PARTICIPANTS

Recruitment was conducted by the clinic's clerical staff or by their care provider. A total of 437 usable T0 surveys and 254 matched and usable T1 surveys were collected.

PRIMARY OUTCOME MEASURES

The survey instrument was focused on five core dimensions of patients' primary care experience (accessibility, continuity, comprehensiveness, responsiveness and outcomes of care) as well as on the SF-12 Short-form Health Survey.

RESULTS

Scores for all dimensions of patients' primary care experience increased significantly: accessibility (T0=5.9, T1=7.9, p<0.001), continuity (T0=5.5, T1=8.8, p<0.001), comprehensiveness (T0=5.6, T1=8.4, p<0.001), responsiveness (T0=7.2, T1=9.5, p<0.001), outcomes of care (T0=5.0, T1=8.3, p<0.001). SF-12 Physical health T-scores also rose significantly (T0=44.8, T1=47.6, p<0.001) but no changes we found in the mental health T scores (T0=45.8, T1=46.3 p=0.709).

CONCLUSIONS

Our results suggest that the NP-led primary care model studied here likely constitutes an effective approach to improve primary care accessibility and quality.

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.

"Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study

BACKGROUND

"Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA1C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians.

OBJECTIVE

This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system.

DESIGN

This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA1C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders.

SETTING

Primary care clinics within the United States Veterans Health Administration.

PARTICIPANTS

38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year.

RESULTS

Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA1C < 7 %.

CONCLUSIONS

Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians.

TWEETABLE ABSTRACT

Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians.

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.

Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

Background

For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs.

Methods

In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey.

Discussion

Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study

BACKGROUND

Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands.

METHODS

We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs.

RESULTS

Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care.

CONCLUSIONS

This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Key determinates of job satisfaction for acute care nurse practitioners in Taiwan

BACKGROUND

Taiwan is a super-aged society, and the shortage of hospital doctors; nurse practitioners (NPs) became vital healthcare providers to fulfill the healthcare demands of the population. The purpose of this study was to explore the key determinates of job satisfaction for NPs in acute care practices using significant practice variables, such as empowerment and burnout.

METHODS

Participants of this descriptive survey study were recruited from a national sample of NPs with membership in the Taiwan Association of Nurse Practitioners. The data were collected utilizing an online questionnaire based on demographic and practice variables, the Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS), the Condition for Work Effectiveness Questionnaire II (CWEQ II), and the Copenhagen Burnout Inventory (CBI). A total of 1,211 NPs completed the online survey. A multiple regression model with the stepwise selection was used to explore job satisfaction.

RESULTS

The mean overall satisfaction score indicated that the level of satisfaction was between slightly dissatisfied and slightly satisfied. Regression results indicated that formal power, work-related burnout, access to information, and needed resources were critical components of job satisfaction, and accounted for 63% of the variance. Moreover, NPs who were married, had a higher annual salary, worked only during the day shift, and had lower patients-related burnout showed better job satisfaction.

CONCLUSIONS

This study provides evidence for healthcare organizations to formulate policies to strengthen NP job satisfaction. Empowerment and burnout are vital factors in NPs' job satisfaction. Healthcare organizations have an obligation to implement policies to empower NPs in practice and provide interventions to mitigate burnout. Implementing these changes will improve job satisfaction and with it the quality of patient care.

A Mixed-Methods Sequential Explanatory Study of the Factors That Impact Nurses' Perspectives toward Nurse Practitioners' Roles in Saudi Arabia

Nurse practitioners' roles need to be clearly defined in Saudi Arabia. Therefore, we aimed to explore potential factors that impact nurses' perspectives toward nurse practitioners' roles and whether they are interested in becoming nurse practitioners. A mixed-methods study design was employed using a questionnaire and focus groups. The survey was sent to nurses working at a public hospital in the Riyadh region. Participants (N = 77) reported that having more nurse practitioners would improve quality of care and patient safety. Additionally, most participants stated that an increased supply of nurse practitioners would have a positive impact on effectiveness, equity of care, and healthcare costs. In regression analysis, participants with favorable perspectives towards nurse practitioners were significantly more likely to have interest in becoming nurse practitioners (odds ratio [95% confidence interval]:1.04 [1.01-1.07]). In the qualitative domain, three positive factors were identified: effective collaboration with other staff, better contribution to quality care and patient safety, and better contribution to evidence-based practice. Two barriers were also determined: lack of motivation to become a nurse practitioner and unclear scope of practice. Results showed that nurse practitioners can provide quality healthcare services that meet patients' different needs. The growing role of this speciality warrants further research to show its value in daily practice.

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.

Experiences in the training of specialist family and community nurses: a qualitative study

Introduction

The specialist Family and Community Nurse Practitioner (FCNP) is a professional who, after a period of training, is qualified to be part of multidisciplinary teams in primary care. The aim of this study was to describe and understand the experiences of nurses during their training process in the specialty of Family and Community Nursing in Spain.

Methods

A descriptive qualitative study was carried out. Participants were recruited by means of convenience sampling from January to April 2022. Sixteen specialist nurses in Family and Community Nursing from different autonomous communities in Spain participated in the study. Twelve individual interviews and one focus group were conducted. Data were analyzed following a thematic analysis method in ATLAS.ti 9.

Results

The results showed two themes and six subthemes: (1) Residency period, more than a training: (a) Training during the residency period; (b) Specializing through a constant struggle; (c) Moderate optimism about the future of the specialty; and (2) A journey from illusion to disappointment: (a) Beginning of the residency: feeling special; (b) During the residency: between satisfaction and misunderstanding; (c) At the end of the residency: power and frustration.

Conclusions

The residency period is important in the training and acquisition of competencies for the Family and Community Nurse Practitioner. Improvements are needed to ensure quality training during residency and to help give visibility to the specialty.

The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review

BACKGROUND

There is an increasing demand for high-quality primary care providers without adequate supply to meet the need. Nurse practitioners (NPs) are uniquely positioned to fill this demand but influence on regulatory practice authority from concerned groups regarding patient safety and quality of care has delayed this as an effective solution.

OBJECTIVES

The objective was to address concerns abovt NP-led care by examining evidence regarding patient safety, clinical outcomes, cost, and patient satisfaction that reflect on the ability of NPs to provide high-quality care within the primary care setting and to compare their ability with standard models of care led by physicians.

DATA SOURCES

A systematic review was completed using PubMed, CINHAL Complete, and Scopus. Using PRISMA guidelines to critique literature and the John's Hopkins Research Evidence Appraisal tool, articles were analyzed comparing the quality of care between NP and physician providers in the primary care setting.

CONCLUSIONS

A total of 11 articles met the criteria and reveal that NPs provide equal or better quality of care for all outcomes outcomes when compared with their physician colleagues.

IMPLICATIONS FOR PRACTICE

Quality patient care provided by NPs in the primary care setting is equal to, and in several cases superior to, that of physicians. Concerns for patient safety and quality care outcomes seem unsupported by data, and state legislatures should continue to grant full practice authority. as an effective source of providing high-quality primary health care.

The impact of organisational commitment and leadership style on job satisfaction of nurse practitioners in acute care practices

AIM

To determine the main factors that affect nurse practitioners' job satisfaction, especially the relationship between organisational commitment and leadership styles in acute care practices.

BACKGROUND

There is little known about the influence of organisational commitment and leadership on NPs' job satisfaction within acute care hospitals.

METHODS

A cross-sectional design with a national online survey that enrolled 1,205 nurse practitioners from the Taiwan Association of Nurse Practitioners to identify potential variables associated with job satisfaction using the multiple regression model.

RESULTS

Organisational commitment (mean=59.47), job satisfaction (mean=173.47), and leadership style (mean ranged from 13.29 to 28) were at a moderate level. Organisational commitment, leadership style, patient load and nurse practitioner advancement levels explained 63% of the variance in nurse practitioners' job satisfaction.

CONCLUSIONS

Organisational commitment and leadership styles, such as idealised influence and individual consideration, are major factors that impact nurse practitioners' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Healthcare organisations should develop policies targeting organisational commitment and managers' leadership styles to improve nurse practitioners' job satisfaction.

State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners

BACKGROUND

During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions.

PURPOSE

To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research.

METHODS

We have conducted a thorough review of the existing literature.

FINDINGS

NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost.

DISCUSSION

The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.

Employing nurse practitioners in general practice: an exploratory survey of the perspectives of managers

INTRODUCTION Establishing the nurse practitioner (NP) workforce in New Zealand is a viable solution to health and workforce challenges in primary health care. General practices have been slow to implement NP services. Managers of general practices are central to the employment and development of NP roles. AIM To explore the perspectives of managers on employing NPs in general practice. METHODS An electronic survey was used to collect demographic and numerical data, which were analysed descriptively and analytically using SPSS (version 26). Written answers to open-ended questions were analysed qualitatively. RESULTS In total, 143 managers participated in the survey (response rate 39.7%); 54 (37.8%) worked in practices employing at least one NP. Of respondents, 88.9% (n = 127) agreed or strongly agreed that NPs could enhance continuity of care (89/143, 62.2%), improved access to services and medications (89/143, 62.2%) and filled a gap that added value to health care (97/143, 67.8%). Practices employing NPs had statistically significant higher levels of agreement about the advantages of NPs than practices not employing NPs. Challenges and enablers to employing NPs were themed under organisational environment, NP scope of practice and role, and NP workforce development. DISCUSSION This exploratory study revealed that there is little knowledge about the NP workforce in surveyed general practices. Ongoing work is required to improve knowledge for employing general practices, including dissemination of information about NP education and training, scope and models of care, and ability to generate business income.

Recent evidence of nurse practitioner outcomes in a variety of care settings

ABSTRACT

When nurse practitioners (NPs) work to expand their scope of practice through state legislatures, the opposing lobbying groups are often physician-led organizations. The main argument against NP independence and limited scope of practice is that NP care is inherently inferior to that of physicians. However, more than three decades of research demonstrates quality and cost outcomes to be equal to or better than that of physicians. This article reviews a wide range of evidence documenting NP competency, satisfaction, and safety, as well as the challenges and consequences when limiting NP scope of practice. The evidence is clear and has not changed in over 30 years, NPs provide access to effective primary care in a variety of settings, equal in quality outcomes, safety, and cost-effectiveness compared with physicians.

Differences in the number of services provided by nurse practitioners and physicians during primary care visits

BACKGROUND

Due to differential training, nurse practitioners (NPs) and physicians may provide different quantities of services to patients.

PURPOSE

To assess differences in the number of laboratory, imagining, and procedural services provided by primary care NPs and physicians.

METHODS

Secondary analysis of 2012-2016 National Ambulatory Medical Care Survey (NAMCS), containing 308 NP-only and 73,099 physician-only patient visits, using multivariable regression and propensity score techniques.

FINDINGS

On average, primary care visits with NPs versus physicians were associated with 0.521 fewer laboratory (95% CI -0.849, -0.192), and 0.078 fewer imaging services (95% CI -0.103,-0.052). Visits for routine and preventive care with NPs versus physicians were associated with 1.345 fewer laboratory (95% CI -2.037,-0.654), and 0.086 fewer imaging services (95% CI -0.118,-0.054) on average. Primary care visits for new problems with NPs versus physicians were associated with 0.051 fewer imaging services (95% CI -0.094,-0.007) on average.

DISCUSSION

NPs provide fewer laboratory and imaging services than physicians during primary care visits.

Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs

Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.

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.

Critical juncture: The doctor of nursing practice and COVID-19

ABSTRACT

The year 2020 was one of tremendous challenge and change for our communities and our profession. As the next decade unfolds, the doctor of nursing practice (DNP) will be required for entry to practice as a nurse practitioner (NP), and we will all continue to recover individually and as a nation from the experiences of the year 2020. Doctor of nursing practice-prepared NPs need to be equipped to take the lead in post-COVID recovery and the challenges the US health care system faces through an increased emphasis on curricula and clinical experiences focused on health disparities, community health, and health promotion.

Frequency of Parathyroid Hormone Assessment in the Evaluation of Hypercalcemia. A Comparison Between Patients With and Without a History of Malignancy in a 20-year Dataset of 20,954 Patients

Background:

The purpose of this study was to evaluate whether a prior diagnosis of malignancy affected the assessment of parathyroid hormone (PTH) in hypercalcemic patients and whether the rate of this assessment changed over time.

Methods:

A retrospective cohort study was designed that included adult patients with hypercalcemia with and without a history of malignancy between January 1, 2000 and December 31, 2019 in the Marshfield Clinic Health System (MCHS). The overall and annual rates of PTH assessment in each group was determined. In patients with a PTH assessment, duration of time and number of elevated serum calcium levels between the first documentation of hypercalcemia and the assessment of PTH were recorded, as was the degree of hypercalcemia.

Results:

Approximately a quarter (23%) of the patients in each group had a PTH assessment. The rate of PTH assessment initially increased over time but later declined significantly. Although a more severe degree of hypercalcemia predicted a greater probability of PTH assessment, the rate of assessment declined with all degrees of hypercalcemia in the last 5 years. While most patients who had a PTH assessed did so within a few months of the first documentation of hypercalcemia, less than half (40%) had a delay of more than 2 years before a PTH level was drawn.

Conclusion:

This lack of appropriate and timely assessment may have significant health consequences in both groups of patients. Better education of providers about the appropriate and timely assessment of PTH in the evaluation of hypercalcemia is urgently needed.

Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels (P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team (P = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states

AIMS

To understand patients' and providers' perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System.

DESIGN

Qualitative exploratory study (in convergent mixed-methods design).

METHODS

Semi-structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis.

RESULTS

We interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers' professional experience outweighed provider type.

CONCLUSIONS

Patients' preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers' perceptions suggest NPs and physicians are both viable providers for primary care.

IMPACT

Nurse Practitioners (NPs): practice authority Veterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care delivery United States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much-needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiences.

Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care

OBJECTIVE

To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients.

DATA SOURCES

Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012.

STUDY DESIGN

We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment.

PRINCIPAL FINDINGS

Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant.

CONCLUSIONS

Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.