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Bohler F, Peters G, Aggarwal N, Harvey K, Bohler JD. The rise of advanced practice provider independence bills: a misguided attempt to address the physician shortage. J Osteopath Med 2024; 124:555-558. [PMID: 39214889 DOI: 10.1515/jom-2024-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
In the past decade, the rise of state legislation that allows for advanced practice provider (APP) independence has grown steadily across the country. Most recently, Montana has enacted House Bill 313, which allows for physician assistant independent practice in primary care services. This is a concerning trend because there is a multitude of studies that demonstrate worsened patient outcomes and increased healthcare expenditures for care delivered by nonphysicians. There are also many unintended consequences that are likely to occur due to this inappropriate expansion of scope of practice for APPs. In this commentary, we outline the ramifications that are likely to occur in states such as Montana that enact legislation that expands the scope of practice for nonphysicians.
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Affiliation(s)
- Forrest Bohler
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Garrett Peters
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nikhil Aggarwal
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Kyle Harvey
- University of California Los Angeles, Los Angeles, CA, USA
| | - J David Bohler
- Gastroenterologist, Bitterroot Health Hospital, Hamilton, MT, USA
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2
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JaKa MM, Rossom RC, Borson S, O'Connor PJ, Zibley LJ, von Sternberg TL, Crain AL, Ekstrom HL, Crouse B, Werner AM, Hanson LR. Confidence in diagnosing and managing care for cognitive impairment in primary care: a survey comparing barriers by primary care clinician type. Fam Pract 2024; 41:761-769. [PMID: 39221923 DOI: 10.1093/fampra/cmae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND As cognitive impairment (CI) prevalence rises and primary care screening becomes commonplace, it is critical to understand how to support clinicians. We describe clinician-reported barriers to diagnosing and managing care for patients with CI in a health system with standardized screening. We also explore whether barriers differ by clinician type-physician or advanced-practice clinician (APC). METHODS Theory-informed surveys were administered to primary care clinicians in a large integrated health system. The survey assessed barriers, confidence in diagnosing CI and managing CI care, beliefs about the consequences of diagnosing CI, and usability of the electronic health record (EHR) to diagnose and manage CI care; it also included open-ended response items. Descriptive statistics and content analysis were used to describe perceived barriers. Differences by clinician type were compared using chi-square. RESULTS Of the 408 eligible clinicians, 249 started the survey and 247 completed the primary outcomes (61% response rate). Many said they were only a little or not at all confident in diagnosing (70%) and managing care for (60%) CI, with specific gaps in confidence in distinguishing types of dementia and having CI-related conversations with patients or family/care partners. APCs reported lower confidence than physicians. Other barriers were lack of time, low usability of EHR, and lack of family/care partner availability. These did not differ by clinician type. Open-ended responses suggest clinicians would like more support for CI care. CONCLUSION Low levels of confidence among other barriers suggest an urgent need to develop and implement effective multifaceted strategies to improve CI care.
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Affiliation(s)
- Meghan M JaKa
- Center for Evaluation and Survey Research, HealthPartners Institute, Bloomington, 55425, United States
| | | | - Soo Borson
- Department of Family Medicine, Keck USC School of Medicine, Los Angeles, 90033, United States
| | | | - Laura J Zibley
- Center for Evaluation and Survey Research, HealthPartners Institute, Bloomington, 55425, United States
| | | | - A Lauren Crain
- HealthPartners Institute, Bloomington, 55425, United States
| | | | - Bethany Crouse
- HealthPartners Institute, Bloomington, 55425, United States
| | - Ann M Werner
- HealthPartners Institute, Bloomington, 55425, United States
| | - Leah R Hanson
- HealthPartners Institute, Bloomington, 55425, United States
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Deng Y, Sang Y, Shang Y, Wu C, Xu X. To explore the application value of nursing staff involved multidisciplinary continuous nursing in stroke patients with limb dysfunction. BMC Health Serv Res 2024; 24:1051. [PMID: 39261901 PMCID: PMC11391790 DOI: 10.1186/s12913-024-11511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/29/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Stroke patients often experience limb dysfunction, which can significantly impact their quality of life and daily living abilities. This study aimed to explore the effectiveness of nursing programs that incorporate multidisciplinary continuing care with the participation of nursing staff for patients with stroke and limb dysfunction. METHODS This was a randomized controlled trial (RCT) conducted from August 2021 to August 2023. Ninety stroke patients were randomly assigned to a control group (n = 45) and an observation group (n = 45). The control group received routine discharge care, while the observation group received multidisciplinary continuing care with the participation of nursing staff. Outcomes measured included Fugl-Meyer Assessment (FMA) scores for upper and lower limb function, quality of life, daily living ability (Barthel Index, MBI), and adverse reactions. RESULTS The FMA scores for upper and lower limbs were significantly higher in the observation group compared to the control group. The observation group also had significantly higher scores in all quality of life dimensions and MBI scores compared to the control group. There were 10 adverse reactions reported in the observation group and 22 in the control group. CONCLUSIONS Implementing multidisciplinary continuing care with the participation of nursing staff for stroke patients with limb dysfunction has a positive effect on improving limb function, quality of life, and daily living abilities, while also being relatively safe.
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Affiliation(s)
- Yuan Deng
- Department of Nursing, Yueyang Vocational Technical College, Yueyang, China.
| | - Yufei Sang
- Medical Service Department, 923 Hospital of Joint Logistic Support Force of PLA, Nanning, China
| | - Yunfeng Shang
- Department of Rehabilitation Medicine Center, Yueyang Central Hospital, Yueyang, China
| | - Chao Wu
- Department of Nursing, Yueyang Vocational Technical College, Yueyang, China
| | - Xiaofeng Xu
- Department of Nursing, Yueyang Vocational Technical College, Yueyang, China
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O'Reilly-Jacob M, Mayanja-Sserebe R, Zwilling J. Continued restrictions on nurse practitioners: A qualitative study of the early implementation of full practice authority in Massachusetts. Nurs Outlook 2024; 72:102249. [PMID: 39067110 DOI: 10.1016/j.outlook.2024.102249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/30/2024]
Abstract
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.
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Affiliation(s)
| | | | - Jana Zwilling
- College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks, ND
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Enckell A, Laine MK, Roitto HM, Raina M, Kauppila T. 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. Scand J Prim Health Care 2024:1-7. [PMID: 38976004 DOI: 10.1080/02813432.2024.2375548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/27/2024] [Indexed: 07/09/2024] Open
Abstract
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.
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Affiliation(s)
- Aina Enckell
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Western Uusimaa Wellbeing Services County, Finland
| | - Merja K Laine
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
| | - Hanna-Maria Roitto
- Clinics of Internal Medicine and rehabilitation, Department of Geriatrics, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marko Raina
- Wellbeing Services County of Vantaa and Kerava, Vantaa, Finland
- Apotti Ltd
| | - Timo Kauppila
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Contandriopoulos D, Bertoni K, McCracken R, Hedden L, Lavergne R, Randhawa GK. Evaluating the cost of NP-led vs. GP-led primary care in British Columbia. Healthc Manage Forum 2024; 37:244-250. [PMID: 38291669 PMCID: PMC11264560 DOI: 10.1177/08404704241229075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
| | | | - Rita McCracken
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Lindsay Hedden
- Simon Fraser University, Burnaby, British Columbia, Canada
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Ivey LA, Flavin P, Vogelaar K, Peck JL. A case for the health welfare of Texans-A nurse practitioner state regulation policy analysis. J Am Assoc Nurse Pract 2024; 36:171-179. [PMID: 37906503 DOI: 10.1097/jxx.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/04/2023] [Indexed: 11/02/2023]
Abstract
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.
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Affiliation(s)
- Laura A Ivey
- Louise Herrington School of Nursing, Baylor University, Dallas, Texas
| | | | - Katy Vogelaar
- Louise Herrington School of Nursing, Baylor University, Dallas, Texas
| | - Jessica L Peck
- Louise Herrington School of Nursing, Baylor University, Dallas, Texas
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Bae K, Norris C, Shakya S, Timmons E. Advanced Practice Registered Nurse Full Practice Authority, Provider Supply, and Health Outcomes: A Border Analysis. Policy Polit Nurs Pract 2024; 25:6-13. [PMID: 38116640 DOI: 10.1177/15271544231212155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
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.
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Affiliation(s)
- Kihwan Bae
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
- West Virginia University, Morgantown, WV, USA
| | - Conor Norris
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
| | - Shishir Shakya
- Shippensburg University of Pennsylvania, Shippensburg, PA, USA
| | - Edward Timmons
- The Knee Center for the Study of Occupational Regulation, Morgantown, WV, USA
- West Virginia University, Morgantown, WV, USA
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Gonzalez JD, Eckhardt AL. Operationalization of Clinical Placements in Graduate Nursing. Nurse Educ 2024; 49:E32-E35. [PMID: 37442122 DOI: 10.1097/nne.0000000000001480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
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.
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Affiliation(s)
- John D Gonzalez
- Clinical Associate Professor (Dr Gonzalez), School of Nursing, University of Texas Medical Branch at Galveston; and Clinical Associate Professor (Dr Eckhardt) and Interim Chair Department of Graduate Nursing (Dr Eckhardt), College of Nursing and Health Innovation, University of Texas at Arlington
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10
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James MT, Scory TD, Novak E, Manns BJ, Hemmelgarn BR, Bello AK, Ravani P, Kahlon B, MacRae JM, Ronksley PE. Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD. Clin J Am Soc Nephrol 2023; 18:1533-1544. [PMID: 38064305 PMCID: PMC10723919 DOI: 10.2215/cjn.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
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.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Novak
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K. Bello
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Bhavneet Kahlon
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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McGowan M, Rose D, Paez M, Stewart G, Stockdale S. Frontline perspectives on adoption and non-adoption of care management tools for high-risk patients in primary care. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100719. [PMID: 37748215 DOI: 10.1016/j.hjdsi.2023.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/22/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Michael McGowan
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA
| | - Monica Paez
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA
| | - Gregory Stewart
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA; Department of Management and Organizations, Tippie College of Business, University of Iowa, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
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Kurtzman ET, Barnow BS, Deoli A. A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants. Nurs Outlook 2023; 71:102062. [PMID: 37866300 DOI: 10.1016/j.outlook.2023.102062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
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.
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Affiliation(s)
- Ellen T Kurtzman
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ.
| | - Burt S Barnow
- Trachtenberg School of Public Policy and Public Administration, The George Washington University, Washington, DC
| | - Aakanksha Deoli
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ
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Contandriopoulos D, Bertoni K, Duhoux A, Randhawa GK. Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience. BMJ Open 2023; 13:e072812. [PMID: 37857545 PMCID: PMC10603457 DOI: 10.1136/bmjopen-2023-072812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023] Open
Abstract
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.
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Affiliation(s)
| | - Katherine Bertoni
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Arnaud Duhoux
- Faculté des Sciences Infirmières, Université de Montréal, Montreal, Québec, Canada
| | - Gurprit K Randhawa
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
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Soltis-Jarrett V. The Future of Psychiatric-Mental Health Nursing: Observe, Reflect, and Take Action to Empower Knowledge for the Greater Good. Issues Ment Health Nurs 2023; 44:1071-1079. [PMID: 37939371 DOI: 10.1080/01612840.2023.2270066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
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.
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Affiliation(s)
- Victoria Soltis-Jarrett
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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15
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Zhou AE, Grant-Kels JM. Ethics of using the Honorific Title "Doctor". J Am Acad Dermatol 2023:S0190-9622(23)02863-3. [PMID: 37751780 DOI: 10.1016/j.jaad.2023.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Albert E Zhou
- Department of Dermatology, University of Connecticut, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
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Schuttner L, Richardson C, Parikh T, Wong ES. "Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study. Int J Nurs Stud 2023; 145:104532. [PMID: 37315453 PMCID: PMC10760981 DOI: 10.1016/j.ijnurstu.2023.104532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Linnaea Schuttner
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Claire Richardson
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Toral Parikh
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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17
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Oh H, White EM, Muench U, Santostefano C, Thapa B, Kosar C, Gadbois EA, Osakwe ZT, Gozalo P, Rahman M. Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia. Alzheimers Dement 2023; 19:3946-3964. [PMID: 37070972 PMCID: PMC10523969 DOI: 10.1002/alz.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 04/19/2023]
Abstract
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.
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Affiliation(s)
- Hyesung Oh
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth M White
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, University of California San Francisco School of Nursing, San Francisco, California, USA
| | - Christopher Santostefano
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Bishnu Thapa
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cyrus Kosar
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Emily A Gadbois
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, New York, USA
| | - Pedro Gozalo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Hynes DM, Govier DJ, Niederhausen M, Tuepker A, Laliberte AZ, McCready H, Hickok A, Rowneki M, Waller D, Cordasco KM, Singer SJ, McDonald KM, Slatore CG, Thomas KC, Maciejewski M, Battaglia C, Perla L. Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study. FRONTIERS IN HEALTH SERVICES 2023; 3:1211577. [PMID: 37654810 PMCID: PMC10465329 DOI: 10.3389/frhs.2023.1211577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/01/2023] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Denise M. Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
- School of Nursing, Oregon Health & Science University, Portland, OR, United States
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
| | - Diana J. Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
- School of Public Health, Oregon Health & Science University & Portland State University, Portland, OR, United States
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
- School of Public Health, Oregon Health & Science University & Portland State University, Portland, OR, United States
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Avery Z. Laliberte
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
| | - Holly McCready
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
| | - Mazhgan Rowneki
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
| | - Dylan Waller
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
| | - Kristina M. Cordasco
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Sara J. Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Kathryn M. McDonald
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Nursing, Baltimore, MD, United States
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, United States
- Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, Portland, OR, United States
| | - Kathleen C. Thomas
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Matthew Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States
- Department of Population Health Sciences & Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, United States
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, CO, United States
- Department of Health Systems, Management & Policy, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lisa Perla
- Rehabilitation Services, Veterans Affairs Central Office, Washington, DC, United States
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Dankers-de Mari EJCM, van Vught AJAH, Visee HC, Laurant MGH, Batenburg R, Jeurissen PPT. The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study. BMC Health Serv Res 2023; 23:580. [PMID: 37280653 DOI: 10.1186/s12913-023-09568-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/17/2023] [Indexed: 06/08/2023] Open
Abstract
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.
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Affiliation(s)
- Ellen J C M Dankers-de Mari
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Radboud Institute for Health Sciences, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Anneke J A H van Vught
- School of Health Studies, HAN University of Applied Sciences, P.O. Box 6960, 6503 GL, Nijmegen, The Netherlands
| | - Hetty C Visee
- Regioplan, Jollemanhof 18, Amsterdam, 1019 GW, The Netherlands
| | - Miranda G H Laurant
- School of Health Studies, HAN University of Applied Sciences, P.O. Box 6960, 6503 GL, Nijmegen, The Netherlands
| | - Ronald Batenburg
- Netherlands Institute for Health Services Research, NIVEL, P.O. Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Patrick P T Jeurissen
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Radboud Institute for Health Sciences, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Sánchez-Muñoz F, Fernández-Medina IM, Granero-Molina J, Suazo-Galdames IC, Nunez-Nagy S, Ventura-Miranda MI, Ruíz-Fernández MD. Experiences in the training of specialist family and community nurses: a qualitative study. Front Public Health 2023; 11:1154084. [PMID: 37213648 PMCID: PMC10192694 DOI: 10.3389/fpubh.2023.1154084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - José Granero-Molina
- Department of Nursing, Physiotherapy and Medicine, University of Almería, Almería, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Temuco, Chile
| | | | - Susana Nunez-Nagy
- Department of Physiotherapy, University of Alcalá, Alcalá de Henares, Madrid, Spain
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Hughes PM, Harless C, Ramage M, Fusco C, Ostrach B. Opioid Use Disorder Practice by Licensure Category in North Carolina. N C Med J 2023; 84:188-193. [PMID: 39302287 DOI: 10.18043/001c.74508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
Background Nurse practitioners, physician assistants, and certified nurse midwives, collectively known as advanced practice providers (APPs), are critical members of the opioid use disorder (OUD) treatment workforce. Few studies compare the OUD treatment practice patterns of APPs relative to physicians. Methods In this cross-sectional study, we distributed a survey examining general substance use disorder (SUD) and OUD-specific treat-ment practices to all licensed physicians and APPs in North Carolina, resulting in a sample of 332 respondents. Respondents were asked about screening, referrals, and Drug Enforcement Administration (DEA) X-waiver status. Waivered providers were asked about prescribing buprenorphine. Differences in practice patterns by provider type were examined using descriptive statistics and chi-squared tests. Results Practice patterns were similar between APPs and physicians; however, more APPs reported screening their patients for SUDs (83.3% versus 69.4%, p = .0045). Of the providers who were waivered to prescribe buprenorphine, APPs and physicians were equally likely to be currently prescribing buprenorphine (75.8% versus 77.1%, p = .8900). Limitations This was a descriptive cross-sectional study using self-report data from a purposive sample and may not be representative of all providers. Conclusions Our results describe practice patterns for APPs and physicians and differences that may be reflective of regulations and therapeutic approaches. Similarities in obtaining an X-waiver and prescribing buprenorphine suggest that reducing restrictions on APPs may result in a larger treatment workforce.
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Affiliation(s)
- Phillip M Hughes
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy
- University of North Carolina Health Sciences Division of Research, Mountain Area Health Education Center
| | - Chase Harless
- University of North Carolina Health Sciences, Mountain Area Health Education Center
- Department of Public Health, East Tennessee State University
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center
| | - Carriedelle Fusco
- Department of Family Medicine, Mountain Area Health Education Center
| | - Bayla Ostrach
- Family Medicine and Medical Anthropology, Boston University School of Medicine
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22
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Huang SS, Chen CY, Kau K, Tsai JM, Tsay SL. Key determinates of job satisfaction for acute care nurse practitioners in Taiwan. BMC Nurs 2023; 22:6. [PMID: 36604678 PMCID: PMC9814220 DOI: 10.1186/s12912-022-01156-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sheng-Shiung Huang
- grid.445025.20000 0004 0532 2244College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
| | - Cheng-Yuan Chen
- grid.412094.a0000 0004 0572 7815National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Kevin Kau
- grid.19188.390000 0004 0546 0241Academic Writing Education Center, National Taiwan University, Taipei, Taiwan
| | - Jung-Mei Tsai
- grid.413593.90000 0004 0573 007XDepartment of Nursing, Mackay Memorial Hospital, Taipei, Taiwan ,grid.445025.20000 0004 0532 2244Department of Nursing, Da-Yeh University, Changhua, Taiwan
| | - Shiow-Luan Tsay
- grid.445025.20000 0004 0532 2244College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
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Kerari A, Bahari G, Aldossery N, Qadhi O, Alghamdi A. A Mixed-Methods Sequential Explanatory Study of the Factors That Impact Nurses' Perspectives toward Nurse Practitioners' Roles in Saudi Arabia. Healthcare (Basel) 2023; 11:146. [PMID: 36611606 PMCID: PMC9819381 DOI: 10.3390/healthcare11010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/17/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Ali Kerari
- Medical Surgical Department, College of Nursing, King Saud University, Riyadh 11421, Saudi Arabia
| | - Ghareeb Bahari
- Nursing Administration and Education Department, College of Nursing, King Saud University, Riyadh 11421, Saudi Arabia
| | | | - Omaimah Qadhi
- Medical Surgical Department, College of Nursing, King Saud University, Riyadh 11421, Saudi Arabia
| | - Alya Alghamdi
- Community, Psychiatric and Mental Health Nursing Department, College of Nursing, King Saud University, Riyadh 11421, Saudi Arabia
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Harrison JM, Kranz AM, Chen AYA, Liu HH, Martsolf GR, Cohen CC, Dworsky M. The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231167013. [PMID: 37102473 PMCID: PMC10150436 DOI: 10.1177/00469580231167013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/28/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Grant R. Martsolf
- RAND Corporation, Pittsburgh, PA,
USA
- University of Pittsburgh School of
Nursing, Pittsburgh, PA, USA
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25
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The Power of Words. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Barnett M, Balkissoon C, Sandhu J. The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review. J Am Assoc Nurse Pract 2022; 34:457-464. [PMID: 34678807 DOI: 10.1097/jxx.0000000000000660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Michael Barnett
- School of Nursing and Health Professions, University of San Francisco, San Francisco, California
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Lei LP, Lin KP, Huang SS, Tung HH, Tsai JM, Tsay SL. The impact of organisational commitment and leadership style on job satisfaction of nurse practitioners in acute care practices. J Nurs Manag 2022; 30:651-659. [PMID: 35174563 DOI: 10.1111/jonm.13562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 02/09/2022] [Accepted: 02/13/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Lee-Pi Lei
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
| | - Kuan-Pin Lin
- Department of Nursing, HungKuang University, Taichung, Taiwan
| | - Sheng-Shiung Huang
- College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
| | - Heng-Hsin Tung
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jung-Mei Tsai
- Department of Nursing, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Nursing, Mackay Medical College, Taipei, Taiwan
| | - Shiow-Luan Tsay
- College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
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Wilkinson M, Biernacki P, Knestrick J. HIV in Primary Care: Case Study of Common Chronic Comorbidities. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Poghosyan L, Pulcini J, Chan GK, Dunphy L, Martsolf GR, Greco K, Todd BA, Brown SC, Fitzgerald M, McMenamin AL, Solari-Twadell PA. State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners. Nurs Outlook 2022; 70:28-35. [PMID: 34763899 PMCID: PMC8346350 DOI: 10.1016/j.outlook.2021.07.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/21/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
| | - Joyce Pulcini
- George Washington University School of Nursing, Ashburn, VA
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Mustafa M, Adams S, Bareham C, Carryer J. Employing nurse practitioners in general practice: an exploratory survey of the perspectives of managers. J Prim Health Care 2021; 13:274-282. [PMID: 34588111 DOI: 10.1071/hc21036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Maher Mustafa
- School of Nursing, Massey University, Palmerston North, New Zealand; and Corresponding author.
| | - Sue Adams
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Corinne Bareham
- School of Psychology, Massey University, Palmerston North, New Zealand; and Victoria University of Wellington, Wellington, New Zealand
| | - Jenny Carryer
- School of Nursing, Massey University, Palmerston North, New Zealand
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Geller DE, Swan BA. Recent evidence of nurse practitioner outcomes in a variety of care settings. J Am Assoc Nurse Pract 2021; 33:771-775. [PMID: 32649383 DOI: 10.1097/jxx.0000000000000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Daniel E Geller
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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32
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Differences in the number of services provided by nurse practitioners and physicians during primary care visits. Nurs Outlook 2021; 69:886-891. [PMID: 34092371 DOI: 10.1016/j.outlook.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/31/2021] [Accepted: 04/10/2021] [Indexed: 11/24/2022]
Abstract
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.
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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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Frazier K, Paez KA, Creek E, Vinci A, Amolegbe A, Hasanbasri A. Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care. Arthritis Care Res (Hoboken) 2021; 74:1593-1601. [PMID: 33973378 DOI: 10.1002/acr.24618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Karen Frazier
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Kathryn A Paez
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Emily Creek
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Arlene Vinci
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Andrew Amolegbe
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
| | - Arifah Hasanbasri
- American Institutes for Research, 1920 Tryon Court, Chapel Hill, NC, 27517, USA
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McNelis AM, Dreifuerst KT, Beebe S, Spurlock D. Types, Frequency, and Depth of Direct Patient Care Experiences of Family Nurse Practitioner Students in the United States. JOURNAL OF NURSING REGULATION 2021. [DOI: 10.1016/s2155-8256(21)00021-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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36
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Comparison of Rural and Urban Utilization of Nurse Practitioners in States With Full Practice Authority. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Moore KS, Hart AM. Critical juncture: The doctor of nursing practice and COVID-19. J Am Assoc Nurse Pract 2021; 33:97-99. [PMID: 33560749 DOI: 10.1097/jxx.0000000000000582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Karen S Moore
- Trudy Busch-Valentine School of Nursing, Saint Louis University, St. Louis, Missouri
| | - Ann Marie Hart
- Fay W. Whitney School of Nursing, University of Wyoming, Laramie, Wyoming
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Sheehan MT, Li YH, Doi SA, Onitilo AA. 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. Clin Med Insights Endocrinol Diabetes 2021; 14:11795514211059494. [PMID: 34866958 PMCID: PMC8637696 DOI: 10.1177/11795514211059494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/22/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Michael T Sheehan
- Department of Endocrinology, Marshfield Clinic Health System, Weston, WI, USA
| | - Ya-Huei Li
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Suhail A Doi
- Department of Population Medicine, College of Medicine, Doha, Qatar
| | - Adedayo A Onitilo
- Department of Oncology, Marshfield Clinic Health System, Weston, WI, USA
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Meyerink BD, Lampman MA, Laabs SB, Foss RM, Garrison GM, Angstman KB, Sobolik GJ, Halasy MP, Fischer KJ, Rosas SL, Maxson JA, Rushlow DR, Horn JL, Matthews MR, Nagaraju D, Thacher TD. Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes. Popul Health Manag 2020; 24:502-508. [PMID: 33216689 DOI: 10.1089/pop.2020.0229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
| | - Michelle A Lampman
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan B Laabs
- Department of Family Medicine, Mayo Clinic, Mankato, Minnesota, USA
| | - Randy M Foss
- Department of Family Medicine, Mayo Clinic, Lake City, Minnesota, USA
| | - Gregory M Garrison
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Kurt B Angstman
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald J Sobolik
- Primary Care and Population Health, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P Halasy
- Department of Physical Medicine and Rehabilitation, Spine Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin J Fischer
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven L Rosas
- Department of Family Medicine, Mayo Clinic, Menomonie, Wisconsin, USA
| | - Julie A Maxson
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - David R Rushlow
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer L Horn
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Marc R Matthews
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Darshan Nagaraju
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
| | - Tom D Thacher
- Department of Family Medicine and Mayo Clinic, Rochester, Minnesota, USA
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40
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Moldestad M, Greene PA, Sayre GG, Neely EL, Sulc CA, Sales AE, Reddy A, Wong ES, Liu CF. Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states. J Adv Nurs 2020; 76:3092-3103. [PMID: 32875584 DOI: 10.1111/jan.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Megan Moldestad
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Preston A Greene
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Emily L Neely
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Christine A Sulc
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Anne E Sales
- VHA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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41
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Nyweide DJ, Lee W, Colla CH. Accountable Care Organizations’ Increase In Nonphysician Practitioners May Signal Shift For Health Care Workforce. Health Aff (Millwood) 2020; 39:1080-1086. [DOI: 10.1377/hlthaff.2019.01144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David J. Nyweide
- David J. Nyweide is a social science research analyst in the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, in Baltimore, Maryland
| | - Woolton Lee
- Woolton Lee is a social science research analyst in the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services
| | - Carrie H. Colla
- Carrie H. Colla is an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire
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42
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Liu CF, Hebert PL, Douglas JH, Neely EL, Sulc CA, Reddy A, Sales AE, Wong ES. Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Serv Res 2020; 55:178-189. [PMID: 31943190 DOI: 10.1111/1475-6773.13246] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Chuan-Fen Liu
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington
| | - Paul L Hebert
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Jamie H Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Emily L Neely
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Christine A Sulc
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Ashok Reddy
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
| | - Anne E Sales
- Center of Innovation for Clinical Management Research, Ann Arbor, Michigan.,Division of Learning and Knowledge Systems, University of Michigan Medical School, Ann Arbor, Michigan
| | - Edwin S Wong
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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