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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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Showstark M, Smith J, Honda T. Understanding the scope of practice of physician associate/physician associate comparable professions using the World Health Organization global competency and outcomes framework for universal health coverage. HUMAN RESOURCES FOR HEALTH 2023; 21:50. [PMID: 37353808 DOI: 10.1186/s12960-023-00828-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/18/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Physician Associate and Physician Associate comparable (PA/PA-comparable) professions are classified by the 2012 International Labour Classification of Occupations within ISCO group 2240 paramedical practitioners. However, to date, there is no single global framework which categorizes and/or describes their scopes of practice, or a single unifying occupational group name. In 2022, the World Health Organization (WHO) published its Global Competency and Outcomes Framework for Universal Health Coverage which focuses on the practice activities for health workers with a pre-service training pathway of 12-48 months, thus including many PA/PA-comparable roles. In this study we describe the similarities and differences between the SOP documents for PA/PA-comparable professions with a pre-service pathway of 12-48 months, thus excluding any extra-training and specializations, from 25 countries using the WHO Framework as a frame of reference. METHODS SOP documents were collected from 25 countries and mapped to the WHO Framework by 3 independent reviewers. We used descriptive statistics to examine the percent agreement between the WHO Framework and SOP documents by country, as well as the ubiquity of each WHO practice activity across the examined documents. To test the hypothesis that country-specific economic indicators and healthcare workforce metrics may be linked to the presence or absence of specific SOP elements, we utilized Wilkoxon and Fisher Exact tests to examine associations between World Bank economic indicators and country specific healthcare workforce metrics and presence/absence of specific WHO Framework practice activities within each SOP. RESULTS We identified significant heterogeneity between the WHO practice activities reported in the 25 SOP documents, particularly related to the provision of individual health services. We also identified statistically significant associations between World Bank economic indicators and country specific healthcare workforce metrics and presence/absence of the following seven practice activities relating to Individual Health, Population Health, and Management and Organization practice domains: (1) "Formulating a judgement following a clinical encounter," (2) "Assessing community health needs" (3) "Planning and delivering community health programmes," (4) "Managing public health communication," (5) "Developing preparedness for health emergencies and disasters, including disease outbreaks," (6) "Providing workplace-based learning and supervision," and (7) "Participating in evaluation and research." In each case, presence of the above practice activities was associated with lower health economic and workforce indicators, suggesting that these SOP practice activities are more common in lower income countries and countries with a smaller per-capita health workforce. CONCLUSIONS The WHO practice activities provide an effective framework to catalogue and compare the responsibilities of PA/PA-comparable professions recorded by country specific SOP documents. This approach could also be used to compare different occupational SOPs within a country, as well as SOPs between countries. The authors propose that additional information relating to the types of procedures and the level of supervision or autonomy would enable a more comprehensive comparison of SOPs, going beyond the granularity offered by the WHO framework. At that level, the evaluation could then be used to inform gap analyses for training needs in the context of migration, or to better understand the health team skill mixes across different countries. The study also offers reflections on the importance of clarity of intended meaning within the SOP documents.
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Affiliation(s)
- Mary Showstark
- Yale School of Medicine Physician Assistant Online Program, 100 Church Street South, Suite A230, New Haven, CT, 06519, USA.
| | - Jami Smith
- Delaware Valley University Physician Assistant Program, 700 E. Butler Ave., Doylestown, PA, 18901, USA
| | - Trenton Honda
- School of Clinical and Rehabilitation Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
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Park JY, Veenstra DL, Wallick CJ, Marcum ZA. Prescribing Alzheimer's Disease treatments by provider type and geographic region: a comparison among physicians, nurse practitioners, and physician assistants. BMC Geriatr 2022; 22:522. [PMID: 35752783 PMCID: PMC9233396 DOI: 10.1186/s12877-022-03176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background The estimated increase in Alzheimer’s Disease (AD) caseload may present a logistical challenge to the US healthcare system. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly delivering primary care to patients with chronic diseases, the nature of their prescribing of AD medications is largely unknown. The primary objective of this study was to compare the prescribing of AD medications across provider types (physician, NP, and PA) and geographic regions. Methods We conducted a retrospective cohort study using IBM MarketScan® commercial and Medicare supplemental claims to examine unique AD prescriptions prescribed between January 1, 2016, and December 31, 2019. Parallel analysis of prescriptions for another geriatric condition, osteoporosis (OP), was also conducted for comparison. Results A total of 103,067 AD prescriptions and 131,773 OP prescriptions were included in analyses. Physicians prescribed most AD prescriptions (95.65%), followed by NPs (3.37%) and PAs (0.98%). Small differences were identified among individual AD medications prescribed by physicians compared to NP/PAs. NPs/PAs prescribed a significantly higher proportion of AD prescriptions in rural as compared to urban areas (z = 0.023, 95%CI [0.018, 0.028]). Conclusion Minimal variation exists in AD prescribing among physicians, NPs, and PAs, but NPs/PAs prescribe more AD prescriptions in rural areas. NPs/PAs, especially in rural areas, may play critical roles in alleviating projected workforce constraints. Further research assessing AD care, health outcomes, and costs by provider type and region is necessary to better guide healthcare workforce planning for AD care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03176-3.
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Affiliation(s)
- Jenny Y Park
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA. .,US Medical Affairs, Genentech, Inc, 1 DNA Way, South San Francisco, CA, 94080, USA.
| | - David L Veenstra
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | | | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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Hohman JA, Patel A, Parikh P, Rothberg MB. Comparing Encounter Characteristics Among Advanced Practice Clinicians and Physicians for Adult Same-Day Visits in Primary and Urgent Care. J Gen Intern Med 2022; 37:689-691. [PMID: 33660210 PMCID: PMC7928179 DOI: 10.1007/s11606-021-06669-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica A Hohman
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.,Cleveland Clinic Community Care, Cleveland, OH, USA
| | - Aditi Patel
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Orthopedic and Rheumatic Institute, Cleveland, OH, USA
| | - Parth Parikh
- Department of Cardiovascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.,Cleveland Clinic Community Care, Cleveland, OH, USA
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Walia B, Banga H, Larsen DA. Increased reliance on physician assistants: an access-quality tradeoff? JOURNAL OF MARKET ACCESS & HEALTH POLICY 2022; 10:2030559. [PMID: 35087646 PMCID: PMC8788342 DOI: 10.1080/20016689.2022.2030559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Bhavneet Walia
- Department of Public Health, Falk College, Syracuse University, Syracuse, NY, USA
| | | | - David A. Larsen
- Department of Public Health, Falk College, Syracuse University, Syracuse, NY, USA
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Evaluating efficiency of counties in providing diabetes preventive care using data envelopment analysis. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021; 21:324-338. [PMID: 34824558 DOI: 10.1007/s10742-020-00237-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
For patients with diabetes, annual preventive care is essential to reduce the risk of complications. Local healthcare resources affect the utilization of diabetes preventive care. Our objectives were to evaluate the relative efficiency of counties in providing diabetes preventive care and explore potential to improve efficiencies. The study setting is public and private healthcare providers in US counties with available data. County-level demographics were extracted from the Area Health Resources File using data from 2010 to 2013, and individual-level information of diabetes preventive service use was obtained from the 2010 Behavioral Risk Factor Surveillance System. 1112 US counties were analyzed. Cluster analysis was used to place counties into three similar groups in terms of economic wellbeing and population characteristics. Group 1 consisted of metropolitan counties with prosperous or comfortable economic levels. Group 2 mostly consisted of non-metropolitan areas between distress and mid-tier levels, while Group 3 were mostly prosperous or comfortable counties in metropolitan areas. We used data enveopement analysis to assess efficiencies within each group. The majority of counties had modest efficiency in providing diabetes preventive care; 36 counties (57.1%), 345 counties (61.1%), and 263 counties (54.3%) were inefficient (efficiency scores < 1) in Group 1, Group 2, and Group 3, respectively. For inefficient counties, foot and eye exams were often identified as sources of inefficiency. Available health professionals in some counties were not fully utilized to provide diabetes preventive care. Identifying benchmarking targets from counties with similar resources can help counties and policy makers develop actionable strategies to improve performance.
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Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood) 2021; 40:1368-1376. [PMID: 34495726 DOI: 10.1377/hlthaff.2021.00401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.
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Affiliation(s)
- David I Auerbach
- David I. Auerbach is an external adjunct faculty member at the Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, in Bozeman, Montana, and is senior director for research and cost trends at the Massachusetts Health Policy Commission, in Boston, Massachusetts
| | - Douglas E Levy
- Douglas E. Levy is an associate professor in the Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, in Boston
| | - Peter Maramaldi
- Peter Maramaldi is a professor in the School of Social Work, Simmons University, in Boston
| | - Robert S Dittus
- Robert S. Dittus is the Albert and Bernard Werthan Professor of Medicine at Vanderbilt University; chief innovation officer and senior vice president for the Vanderbilt Health Affiliated Network; and director of the Geriatric Research, Education, and Clinical Center at the Veterans Affairs Tennessee Valley Healthcare System, in Nashville, Tennessee
| | - Joanne Spetz
- Joanne Spetz is director and Brenda and Jeffrey L. Kang Presidential Chair in Healthcare Finance at the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco, in San Francisco, California
| | - Peter I Buerhaus
- Peter I. Buerhaus is a professor of nursing and director of the Center for Interdisciplinary Health Workforce Studies, both in the College of Nursing, Montana State University
| | - Karen Donelan
- Karen Donelan is the Stuart H. Altman Chair in U.S. Health Policy at the Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts. At the time this work was performed, she was a senior scientist at the Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, and an associate professor in the Department of Medicine at Harvard Medical School, in Boston
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Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants? Med Care 2020; 58:681-688. [PMID: 32265355 DOI: 10.1097/mlr.0000000000001326] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.
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Huang N, Raji M, Lin YL, Chou LN, Kuo YF. Nurse Practitioner Involvement in Medicare Accountable Care Organizations: Association With Quality of Care. Am J Med Qual 2020; 36:171-179. [PMID: 32715726 DOI: 10.1177/1062860620935199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to examine trend and care quality outcomes associated with nurse practitioner (NP) involvement in Accountable Care Organizations (ACOs) via a cross-sectional study of 521 Medicare Shared Savings Program ACOs during 2014 to 2016. Data include ACO provider/beneficiary files, Medicare claims, and ACO performance data with a focus on Medicare beneficiaries with diabetes, chronic obstructive pulmonary disease, or heart failure. ACO care quality measures were stratified by NP involvement and adjusted for patient, provider, and ACO factors. NP involvement was highest in larger ACOs, states that allow NPs full scope of practice, and rural areas. Greater involvement was associated with fewer readmissions and higher scores on measures of preventive care but not chronic disease and medication management. Greater NP involvement in ACOs was associated with improvement in some care quality measures. With NPs' increasing involvement in ACOs, more research is needed to understand the NP role in processes and outcomes of care.
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Affiliation(s)
- Nicole Huang
- University of Texas Medical Branch, Galveston, TX
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Larson EH, Frogner BK. Characteristics of Physician Assistant Students Planning to Work in Primary Care: A National Study. J Physician Assist Educ 2019; 30:200-206. [PMID: 31651728 DOI: 10.1097/jpa.0000000000000275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE While the number of physician assistants (PAs) participating in the primary care workforce continues to rise, the proportion of PAs practicing in primary care rather than other specialties has decreased. The purpose of this study was to identify the characteristics of matriculating PA students planning to enter primary care specialties and compare them with students planning on entering other specialties. METHODS Data from the Physician Assistant Education Association Matriculating Student Survey (MSS) from 2013 and 2014 were analyzed. In a series of bivariate analyses, demographic characteristics, educational backgrounds, clinical experiences, and practice expectations of students intending to enter primary care practice were compared with those of their counterparts who did not intend to enter primary care. Logistic regression was used to assess the overall importance of demographic, background, and practice expectations variables on practice intentions. RESULTS A total of 9283 students responded to the MSS from 2013 and 2014. More than half (58.3%) stated an intention to practice in primary care upon graduation. Those students were more likely than their counterparts to be married, to be Hispanic or Asian, and to have participated in community service prior to starting PA training. They were also less likely to view high income as essential to their careers and more likely to view practicing in rural or underserved areas favorably. CONCLUSIONS The findings of this study could be used to identify student characteristics associated with an interest in primary care and could contribute to more successful student recruitment and PA curriculum design, especially for PA training programs with a mission focused on producing primary care PAs.
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Affiliation(s)
- Eric H Larson
- Eric H. Larson, PhD, is a research professor and director of the WWAMI Rural Health Research Center, MEDEX Northwest, Department of Family Medicine at the University of Washington, Seattle, Washington. Bianca K. Frogner, PhD, is an associate professor and director of the Center for Health Workforce Studies, Department of Family Medicine at the University of Washington, Seattle, Washington
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Abraham CM, Norful AA, Stone PW, Poghosyan L. Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review. NURSING ECONOMIC$ 2019; 37:293-305. [PMID: 34616101 PMCID: PMC8491992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Globally, advanced practice nurses (APNs) provide high-quality chronic disease care to patients, yet the cost-effectiveness of their services is minimally explored. This review aims to determine the cost-effectiveness of chronic disease care provided by APNs compared to physicians globally.
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12
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Moote M, Krsek C, Kleinpell R, Todd B. Republished: Physician Assistant and Nurse Practitioner Utilization in Academic Medical Centers. Am J Med Qual 2019; 34:465-472. [DOI: 10.1177/1062860619873216] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.
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Affiliation(s)
- Marc Moote
- University of Michigan Hospitals and Health Centers, Ann Arbor, MI
| | | | | | - Barbara Todd
- University of Pennsylvania Health System, Philadelphia, PA
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Butala NM, Hidrue MK, Swersey AJ, Singh JP, Weilburg JB, Ferris TG, Armstrong KA, Wasfy JH. Measuring individual physician clinical productivity in an era of consolidated group practices. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2019; 7:S2213-0764(18)30051-4. [PMID: 30744992 DOI: 10.1016/j.hjdsi.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 01/30/2019] [Accepted: 02/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND As physician groups consolidate and value-based payment replaces traditional fee-for-service systems, physician practices have greater need to accurately measure individual physician clinical productivity within team-based systems. We compared methodologies to measure individual physician outpatient clinical productivity after adjustment for shared practice resources. METHODS For cardiologists at our hospital between January 2015 and June 2016, we assessed productivity by examining completed patient visits per clinical session per week. Using mixed-effects models, we sequentially accounted for shared practice resources and underlying baseline characteristics. We compared mixed-effects and Generalized Estimating Equations (GEE) models using K-fold cross validation, and compared mixed-effect, GEE, and Data Envelopment Analysis (DEA) models based on ranking of physicians by productivity. RESULTS A mixed-effects model adjusting for shared practice resources reduced variation in productivity among providers by 63% compared to an unadjusted model. Mixed-effects productivity rankings correlated strongly with GEE rankings (Spearman 0.99), but outperformed GEE on K-fold cross validation (root mean squared error 2.66 vs 3.02; mean absolute error 1.89 vs 2.20, respectively). Mixed-effects model rankings had moderate correlation with DEA model rankings (Spearman 0.692), though this improved upon exclusion of outliers (Spearman 0.755). CONCLUSIONS Mixed-effects modeling accounts for significant variation in productivity secondary to shared practice resources, outperforms GEE in predictive power, and is less vulnerable to outliers than DEA. IMPLICATIONS With mixed-effects regression analysis using otherwise easily accessible administrative data, practices can evaluate physician clinical productivity more fairly and make more informed management decisions on physician compensation and resource allocation.
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Affiliation(s)
- Neel M Butala
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston, MA, United States
| | | | - Jagmeet P Singh
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jeffrey B Weilburg
- Massachusetts General Physicians Organization, Boston, MA, United States
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Katrina A Armstrong
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Massachusetts General Physicians Organization, Boston, MA, United States.
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Beogo I, Darboe A, Adesanya OA, Rojas BM. Choosing between nurse-led and medical doctor-led from private for-profit versus non-for-profit health facilities: A household survey in urban Burkina Faso. PLoS One 2018; 13:e0200233. [PMID: 30044796 PMCID: PMC6059411 DOI: 10.1371/journal.pone.0200233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 06/22/2018] [Indexed: 11/29/2022] Open
Abstract
Background Providers’ qualification (Medical doctor [MD] or nurse); type of care facility ownership (for-profit [FP] or not-for-profit [NFP]) may all influence individuals’ healthcare-seeking behavior and therefore merits empirical assessment to provide valuable evidence-informed policy orientation in the present context of private health system development. Previous studies have not examined these factors in combination, especially within the urban context of sub-Sahara Africa, where the private sector is rapidly growing. This study aims to explore factors associated with urban residents’ preferences between private MD-led and private nurse-led outpatient care and how these factors vary by type of private health facility ownership (FP and NFP) and levels of disease severity (severe and non-severe cases). Methods A cross-sectional household survey was conducted in July-November 2011 on a random final sample of 2064 adults (646 households). We used a face-to-face interview to capture participants’ choice of provider and their associated factors. A multivariable logistic regression was applied. Results For severe conditions, participants, almost equally sought FP and NFP facilities, only 36.4% preferred nurses compared to MDs, while for non-severe cases 53.2% preferred FP facilities and only 29.2% patronized nurses. For non-severe conditions, university educated were more likely to use MDs-led FP compared to nurse-led FP facilities (Odds Ratio [OR] = 4.66, 95% confidence interval [CI] = 2.62–8.30) and MD-led FP over MD-led NFP facilities (OR = 1.03, 95%CI = 1.01–1.04), for severe health conditions. Having insurance predicted MD-led FP preference over nurse-led FP. Furthermore, insurance predicted the preference for MD-led FP over MD-led NFP facilities. Employment did not distinguish participants’ choice of provider. Conclusion The findings suggest that, at different levels, MDs and nurses from FP and NFP facilities importantly contribute to health services delivery regardless of the severity of health conditions. The results offer some valuable evidence for policy orientation in the current rising tide of the private system, including workforce development, and practitioners' role definition. We suggested that health insurance mechanism would reinforce the private health services utilization and could enhance progress towards the attainment of Sustainable Development Goals.
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Affiliation(s)
- Idrissa Beogo
- Centre de recherche en gestion des services de santé, FSA-ULaval-CHU de Québec UL–IUCPQ-UL, Pavillon Palasis-Prince, Université Laval, Québec (Qc), Canada
- École Nationale de Santé Publique, Ouagadougou, Ouagadougou, Burkina Faso
- * E-mail:
| | - Amadou Darboe
- The University of Melbourne, School of Population and Global Health, Parkville, Victoria, Australia
| | - Oluwafunmilade A. Adesanya
- Institute of Public Health, International Health Program, National Yang Ming University, Beitou District, Taipei, Taiwan
| | - Bomar Mendez Rojas
- Institute of Public Health, International Health Program, National Yang Ming University, Beitou District, Taipei, Taiwan
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Stein N, Brooks K. A Fully Automated Conversational Artificial Intelligence for Weight Loss: Longitudinal Observational Study Among Overweight and Obese Adults. JMIR Diabetes 2017; 2:e28. [PMID: 30291087 PMCID: PMC6238835 DOI: 10.2196/diabetes.8590] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/11/2017] [Accepted: 10/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background Type 2 diabetes is the most expensive chronic disease in the United States. Two-thirds of US adults have prediabetes or are overweight and at risk for type 2 diabetes. Intensive in-person behavioral counseling can help patients lose weight and make healthy behavior changes to improve their health outcomes. However, with the shortage of health care providers and associated costs, such programs do not adequately service all patients who could benefit. The health care system needs effective and cost-effective interventions that can lead to positive health outcomes as scale. This study investigated the ability of conversational artificial intelligence (AI), in the form of a standalone, fully automated text-based mobile coaching service, to promote weight loss and other health behaviors related to diabetes prevention. This study also measured user acceptability of AI coaches as alternatives to live health care professionals. Objective The objective of this study was to evaluate weight loss, changes in meal quality, and app acceptability among users of the Lark Weight Loss Health Coach AI (HCAI), with the overarching goal of increasing access to compassionate health care via mobile health. Lessons learned in this study can be applied when planning future clinical trials to evaluate HCAI and when designing AI to promote weight loss, healthy behavior change, and prevention and self-management of chronic diseases. Methods This was a longitudinal observational study among overweight and obese (body mass index ≥25) participants who used HCAI, which encourages weight loss and healthy diet choices through elements of cognitive behavioral therapy. Weight loss, meal quality, physical activity, and sleep data were collected through user input and, for sleep and physical activity, partly through automatic detection by the user’s mobile phone. User engagement was assessed by duration and amount of app use. A 4-question in-app user trust survey assessed app usability and acceptability. Results Data were analyzed for participants (N=70) who met engagement standards set forth by the Centers for Disease Control and Prevention criteria for Diabetes Prevention Program, a clinically proven weight loss program focused on preventing diabetes. Weight loss (standard error of the mean) was 2.38% (0.69%) of baseline weight. The average duration of app use was 15 (SD 1.0) weeks, and users averaged 103 sessions each. Predictors of weight loss included duration of AI use, number of counseling sessions, and number of meals logged. Percentage of healthy meals increased by 31%. The in-app user trust survey had a 100% response rate and positive results, with a satisfaction score of 87 out of 100 and net promoter score of 47. Conclusions This study showed that use of an AI health coach is associated with weight loss comparable to in-person lifestyle interventions. It can also encourage behavior changes and have high user acceptability. Research into AI and its application in telemedicine should be pursued, with clinical trials investigating effects on weight, health behaviors, and user engagement and acceptability.
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Affiliation(s)
- Natalie Stein
- Division of Public Health, College of Human Medicine, Michigan State University, Flint Campus, MI, United States
| | - Kevin Brooks
- Division of Public Health, College of Human Medicine, Michigan State University, East Lansing, MI, United States
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Markowitz S, Adams EK, Lewitt MJ, Dunlop AL. Competitive effects of scope of practice restrictions: Public health or public harm? JOURNAL OF HEALTH ECONOMICS 2017; 55:201-218. [PMID: 28778349 DOI: 10.1016/j.jhealeco.2017.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 06/07/2023]
Abstract
The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy.
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A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Med Care 2017; 55:615-622. [DOI: 10.1097/mlr.0000000000000689] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Davis MA, Guo C, Titler MG, Friese CR. Advanced practice clinicians as a usual source of care for adults in the United States. Nurs Outlook 2017; 65:41-49. [DOI: 10.1016/j.outlook.2016.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/22/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022]
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Yao NA, Rose K, LeBaron V, Camacho F, Boling P. Increasing Role of Nurse Practitioners in House Call Programs. J Am Geriatr Soc 2016; 65:847-852. [DOI: 10.1111/jgs.14698] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nengliang Aaron Yao
- Department of Public Health Sciences; University of Virginia; Charlottesville Virginia
| | - Karen Rose
- College of Nursing; The University of Tennessee Knoxville; Knoxville Tennessee
| | - Virginia LeBaron
- School of Nursing; University of Virginia; Charlottesville Virginia
| | - Fabian Camacho
- Department of Public Health Sciences; University of Virginia; Charlottesville Virginia
| | - Peter Boling
- Division of Geriatric Medicine; Virginia Commonwealth University; Richmond Virginia
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Efficiency of Ontario primary care physicians across payment models: a stochastic frontier analysis. HEALTH ECONOMICS REVIEW 2016; 6:22. [PMID: 27271177 PMCID: PMC4894855 DOI: 10.1186/s13561-016-0101-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/01/2016] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada. METHODS Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits. RESULTS Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.
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Affiliation(s)
- Maude Laberge
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Dr, Room 3111, Gainesville, FL, 32610, USA.
- Canadian Centre for Health Economics, Toronto, Canada.
| | - Walter P Wodchis
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Toronto Rehabilitation Institute, Toronto, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Audrey Laporte
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
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Abstract
In response to increased demand for primary care services under the Affordable Care Act, the national network of community health centers (CHCs) will play an increasingly prominent role. CHCs have a broad staffing model that includes extensive use of physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). Between 2007 and 2012, the number of PAs, NPs, and CNMs at CHCs increased by 61%, compared with 31% for physicians. However, several policy and payment issues jeopardize CHCs' ability to expand their workforce and meet the current and rising demand for care.
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Resnick CM, Daniels KM, Flath-Sporn SJ, Doyle M, Heald R, Padwa BL. Physician Assistants Improve Efficiency and Decrease Costs in Outpatient Oral and Maxillofacial Surgery. J Oral Maxillofac Surg 2016; 74:2128-2135. [PMID: 27528102 DOI: 10.1016/j.joms.2016.06.195] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/14/2016] [Accepted: 06/27/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the effects on time, cost, and complication rates of integrating physician assistants (PAs) into the procedural components of an outpatient oral and maxillofacial surgery practice. MATERIALS AND METHODS This is a prospective cohort study of patients from the Department of Plastic and Oral Surgery at Boston Children's Hospital who underwent removal of 4 impacted third molars with intravenous sedation in our outpatient facility. Patients were separated into the "no PA group" and PA group. Process maps were created to capture all activities from room preparation to patient discharge, and all activities were timed for each case. A time-driven activity-based costing method was used to calculate the average times and costs from the provider's perspective for each group. Complication rates were calculated during the periods for both groups. Descriptive statistics were calculated, and significance was set at P < .05. RESULTS The total process time did not differ significantly between groups, but the average total procedure cost decreased by $75.08 after the introduction of PAs (P < .001). The time that the oral and maxillofacial surgeon was directly involved in the procedure decreased by an average of 19.2 minutes after the introduction of PAs (P < .001). No significant differences in postoperative complications were found. CONCLUSIONS The addition of PAs into the procedural components of an outpatient oral and maxillofacial surgery practice resulted in decreased costs whereas complication rates remained constant. The increased availability of the oral and maxillofacial surgeon after the incorporation of PAs allows for more patients to be seen during a clinic session, which has the potential to further increase efficiency and revenue.
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Affiliation(s)
- Cory M Resnick
- Instructor, Harvard School of Dental Medicine; Attending Oral and Maxillofacial Surgeon, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA.
| | - Kimberly M Daniels
- Research Data Manager, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Susan J Flath-Sporn
- Quality Improvement Specialist, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Michael Doyle
- Research Study Assistant, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Ronald Heald
- Department Director, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Bonnie L Padwa
- Associate Professor, Harvard School of Dental Medicine; Oral Surgeon in Chief, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
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Commentaries on health services research. JAAPA 2016. [DOI: 10.1097/01.jaa.0000496970.31667.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mafi JN, Wee CC, Davis RB, Landon BE. Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians. Ann Intern Med 2016; 165:237-44. [PMID: 27322541 PMCID: PMC5584613 DOI: 10.7326/m15-2152] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. OBJECTIVE To compare use of low-value services among U.S. APCs and physicians. DESIGN Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP). SETTING National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. PATIENTS Patients presenting with upper respiratory infections (URIs), back pain, or headache. MEASUREMENTS Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). RESULTS 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. LIMITATION NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. CONCLUSION APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions. PRIMARY FUNDING SOURCE U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.
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Sun E. Does the Modifier "QZ" Accurately Reflect Independent Nurse Anesthetist Practice: And Why Does It Matter? A & A CASE REPORTS 2016; 6:220-221. [PMID: 27032042 DOI: 10.1213/xaa.0000000000000254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Eric Sun
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
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Hevesy M, Aitchison R, Ruiz A, Bednar S. Nurse practitioners and physician assistants in primary care: An update of changes since 2008. Dis Mon 2016; 62:23-36. [DOI: 10.1016/j.disamonth.2016.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Grout RL, Beal SJ, Kahn JA, Widdice LE. Provider-Level Characteristics Associated With Adolescent Varicella, Meningococcal, and Human Papillomavirus Immunization Initiation. Clin Pediatr (Phila) 2016; 55:44-7. [PMID: 25963176 DOI: 10.1177/0009922815584215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE We examined patient- and provider-level factors associated with initiation of three adolescent immunizations among 13 to 18 year olds in an adolescent primary care clinic. METHODS Data were extracted retrospectively from medical records. Logistic regression models identified associations with immunization initiation. Post hoc analyses stratified by gender were conducted to examine provider-type contribution to human papillomavirus (HPV) immunization initiation. RESULTS Among 2932 adolescents, rates of meningococcal and varicella immunization initiation differed by age. Girls were more likely to have initiated HPV immunization than boys. The probability of girls initiating HPV immunization was the same when last seen by advanced practice nurses (APNs) versus physicians, but the probability of boys initiating HPV immunization was lower when last seen by APNs. CONCLUSIONS Differences in HPV immunization initiation were observed between genders, and for boys, between APN versus physician at last clinic visit. This may reflect changes to HPV immunization recommendations for boys and APNs having shorter clinic visits.
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Affiliation(s)
- Rebecca L Grout
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH USA
| | - Sarah J Beal
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH USA
| | - Jessica A Kahn
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH USA
| | - Lea E Widdice
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH USA
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Perloff J, DesRoches CM, Buerhaus P. Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians. Health Serv Res 2015; 51:1407-23. [PMID: 26707840 DOI: 10.1111/1475-6773.12425] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). DATA SOURCE Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010. STUDY DESIGN Retrospective cohort design using propensity score weighted regression. DATA EXTRACTION METHODS Beneficiaries cared for by a random sample of NPs and primary care physicians. PRINCIPAL FINDINGS After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well. CONCLUSIONS This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.
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Affiliation(s)
| | | | - Peter Buerhaus
- College of Nursing, Montana State University, Bozeman, MT
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Beogo I, Liu CY, Dlamini CP, Gagnon MP. Registered Nurse to Bachelor of Science in Nursing: nesting a fast-track to traditional generic program, teachings from nursing education in Burkina Faso. BMC Nurs 2015; 14:66. [PMID: 26633940 PMCID: PMC4667505 DOI: 10.1186/s12912-015-0118-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 11/27/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Nursing education has evolved over time to fit societies' increasing care needs. Innovations in nursing education draw thorny debates on potential jeopardy in the quality, safety, and efficacy of nurse graduates. Accelerated nursing education programs have been among landmark strategic changes to address the persistent bedside nurse shortage. Despite the dearth of empirical studies in sub-Saharan Africa (SSA), the National School of Public Health of Burkina Faso has developed a State Diploma Nursing (SDN) fast-track program. With innovative features, the program is nested into the traditional SDN program. This study investigates preliminary outcomes of the implemented policy using the initial cohort that went through the program. Comparison of the traditional generic program and the fast-track one is drawn to inform nursing education policy. METHODS The study was conducted in the three campuses delivering the SDN program. Data collected from a representative sample included 255 students from the 2006-2009 cohort, after concluding the program. Surveyed students were assessed according to the program entry status. Outcomes were measured using students' academic performance. Besides descriptive analysis, bivariate t-test, F-test, and multivariate ordinary least square regression (OLSR) were employed to determine the comparative pattern between the traditional generic and the newly nested fast-track program. Students' varied statuses (private pre-registration, state pre-registration, private post-registration, and state post-registration) were kept to better outline the findings trend. RESULTS A fifth (19.6 %) of surveyed students were enrolled in the fast-track stream from which, one third (33.7 %) consisted of post-registered students. Fast-track students comparatively achieved the best academic performance (mean: 73.68/100, SD: 5.52). Multivariate OLSR confirmed that fast-track students performed better (β: 5.559, p < 0.001), and further informed differences between campuses. Students entry status also displayed significant differences, yet the academic performance of post-registered students from traditional generic versus fast-track was similar (p = 0.409). CONCLUSION Findings suggest that fast-track program students performed better than the ones from the traditional generic program. The uniqueness and success of this mixed nursing program experience sheds light for nursing educators engaged in policy making. The study results can serve as a crucial foundation for policymakers to alleviate the nurse shortage in SSA.
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Affiliation(s)
- Idrissa Beogo
- École Nationale de Santé Publique, Ouagadougou, Burkina Faso
- Faculté des sciences infirmières, Université Laval, Pavillon Ferdinand-Vandry, 1050, Avenue de la Médecine, Québec, Québec G1V 0A6 Canada
| | - Chieh-Yu Liu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Colile P. Dlamini
- University of Swaziland, Faculty of Health Sciences, Mbabane, Swaziland
| | - Marie-Pierre Gagnon
- Faculté des sciences infirmières, Université Laval, Pavillon Ferdinand-Vandry, 1050, Avenue de la Médecine, Québec, Québec G1V 0A6 Canada
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Influence of provider mix and regulation on primary care services supplied to US patients. HEALTH ECONOMICS POLICY AND LAW 2015; 11:193-213. [PMID: 26443665 DOI: 10.1017/s1744133115000390] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structure's influence on productivity, less research has explored the link between provider mix and access for different patient types - which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.
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Hawkins CM, Bowen MA, Gilliland CA, Walls DG, Duszak R. The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications. J Am Coll Radiol 2015; 12:898-904. [DOI: 10.1016/j.jacr.2015.03.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/23/2015] [Indexed: 01/05/2023]
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Hawkins CM, Bowen MA, Gilliland CA, Walls DG, Duszak R. The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Regulatory, Billing, and Compliance Perspectives. J Am Coll Radiol 2015; 12:776-81. [DOI: 10.1016/j.jacr.2015.03.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/23/2015] [Indexed: 01/02/2023]
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Abstract
BACKGROUND In 2003, the Minnesota legislature revised the Dental Practice Act to include restorative procedures in the scope of practice for registered dental assistants (RDAs) and registered dental hygienists (RDHs). The authors examined these practitioners' characteristics and made comparisons on the basis of their use of restorative function (RF) training and their practices' locations. They also examined practice type, models of implementation and perceived outcomes. METHODS The authors mailed a survey to all RF-certified RDAs and RDHs in Minnesota (N = 387). They used descriptive statistics to summarize the data and t tests and Fisher exact tests (P <.0001) to make comparisons between groups. RESULTS The authors received 243 surveys (63 percent). Less than one-half (38 percent) of the RF-certified practitioners performed RFs. Of these, 29 percent were RDHs and 71 percent were RDAs. These practitioners performed RFs most often by working with a dentist or when time allowed. They perceived increased access to dental care and an increase in the number of patients treated to be outcomes of performing RFs. CONCLUSIONS The results of this survey indicated use of restorative procedures varied greatly by practitioner type. The perceptions of those who performed RFs indicated they had a positive effect on dental practice. PRACTICAL IMPLICATIONS The addition of RF-certified personnel to the dental team has the potential to increase the number of patients seen in practice and the job satisfaction of team members.
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Drennan VM, Halter M, Brearley S, Carneiro W, Gabe J, Gage H, Grant R, Joly L, de Lusignan S. Investigating the contribution of physician assistants to primary care in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02160] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPrimary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.ObjectiveTo investigate the contribution of PAs to the delivery of patient care in primary care services in England.DesignA mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.ResultsThe rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.ConclusionsPAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Vari M Drennan
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Mary Halter
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Sally Brearley
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Wilfred Carneiro
- Directorate of Corporate Affairs, St George’s Healthcare NHS Trust, London, UK
| | - Jonathan Gabe
- Centre for Criminology and Sociology, Royal Holloway, University of London, London, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Robert Grant
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Louise Joly
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
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Aghili R, Khamseh M, Malek M, Banikarimi A, Baradaran H, Ebrahim Valojerdi A. Development and validation of diabetes empowerment questionnaire in Iranian people with type 2 diabetes. Int Nurs Rev 2013; 60:267-73. [DOI: 10.1111/inr.12007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- R. Aghili
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
| | - M.E. Khamseh
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
| | - M. Malek
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
| | - A.S. Banikarimi
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
| | - H.R. Baradaran
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
| | - A. Ebrahim Valojerdi
- Endocrine Research Center (Firouzgar); Institute of Endocrinology and Metabolism; Tehran University of Medical Sciences; Tehran; Iran
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Abstract
OBJECTIVE Physician assistants (PAs) are increasingly utilized in the health care workforce and should be aware of how their interpersonal and technical skills are perceived by patients. The purpose of this study was to test associations among Perceived Interpersonal Care, Perceived Technical Care, and Global Satisfaction. METHODS This cross-sectional telephone survey of recently discharged trauma patients tested a structural equation model which hypothesized that interpersonal satisfaction ratings predicted technical care and global satisfaction ratings. RESULTS A total of 251 completed surveys were analyzed. Results indicated a relationship among interpersonal care, technical care, and global satisfaction. Satisfaction with interpersonal care predicted satisfaction with technical care. CONCLUSION In this study of how satisfied recently discharged trauma patients are with care by physician assistants, perceptions of technical care were associated with perceptions of interpersonal care, or how the patient was treated as a person. Since physician assistants have direct patient contact, this association demonstrates the strength of the PA-patient relationship as an asset to the health care organization.
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Bakerjian D, Harrington C. Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians. Res Gerontol Nurs 2012; 5:163-73. [PMID: 22716651 DOI: 10.3928/19404921-20120605-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 08/01/2011] [Indexed: 11/20/2022]
Abstract
The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.
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Affiliation(s)
- Debra Bakerjian
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.
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Torok H, Lackner C, Landis R, Wright S. Learning needs of physician assistants working in hospital medicine. J Hosp Med 2012; 7:190-4. [PMID: 22173947 DOI: 10.1002/jhm.1001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 09/14/2011] [Accepted: 10/16/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hospital Medicine is growing rapidly, and the number of physician assistants (PAs) in this field is expected to grow. However, there is no available data related to the learning needs of PA hospitalists. OBJECTIVE To conduct a needs assessment for PA hospitalists who may be embarking on a hospitalist career. DESIGN Cross-sectional survey based on the Core Competencies in Hospital Medicine. SETTING/PARTICIPANTS A sample of hospitalist PAs working in the United States. MEASUREMENTS Amount of experience with core diagnoses and procedures, preferences for additional training that would have prepared them to function as hospitalist PAs. RESULTS Sixty-nine PAs responded (response rate, 67%). Among the core clinical conditions, respondents had the most experience in managing diabetes and urinary tract infections and were least experienced with health care-associated pneumonias and sepsis syndrome. Over 90% rarely performed core competency procedures other than electrocardiogram and chest X-ray interpretations. The top 3 content areas that PA hospitalists believed would have helped to better prepare them to care for inpatients were palliative care (percent of PAs who agreed or strongly agreed: 85%), nutrition for hospitalized patients (84%), and consultations (64%). Almost all (91%) indicated that they would have been interested in formal postgraduate hospital medicine training even if it meant having a lower stipend during the first year on the job. CONCLUSIONS This is the first national data on self-perceived learning needs of PA hospitalists. The results may prove helpful for both PAs entering hospitalist careers and for the physician groups looking to hire them.
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Affiliation(s)
- Haruka Torok
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. HEALTH & SOCIAL CARE IN THE COMMUNITY 2012; 20:20-31. [PMID: 21851446 PMCID: PMC3903046 DOI: 10.1111/j.1365-2524.2011.01021.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Shortages of primary care doctors are occurring globally; one means of meeting this demand has been the use of physician assistants (PAs). Introduced in the United States in the late 1960s to address doctor shortages, the PA movement has grown to over 75,000 providers in 2011 and spread to Australia, Canada, Great Britain, the Netherlands, Germany, Ghana and South Africa. A purposeful literature review was undertaken to assess the contribution of PAs to primary care systems. Contemporary studies suggest that PAs can contribute to the successful attainment of primary care functions, particularly the provision of comprehensive care, accessibility and accountability. Employing PAs seems a reasonable strategy for providing primary care for diverse populations.
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Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual 2011; 26:452-60. [PMID: 21555487 DOI: 10.1177/1062860611402984] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.
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Affiliation(s)
- Marc Moote
- University of Michigan Hospitals and Health Centers, Office of Clinical Affairs, 1500 E.Medical Center Drive, Ann Arbor, MI 48109-0825, USA.
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Lieberman SA, McCallum RM, Anderson GD. A golden opportunity: the coevolution of medical and education homes. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:1342. [PMID: 22030641 DOI: 10.1097/acm.0b013e3182308ddc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Zwijnenberg NC, Bours GJJW. Nurse practitioners and physician assistants in Dutch hospitals: their role, extent of substitution and facilitators and barriers experienced in the reallocation of tasks. J Adv Nurs 2011; 68:1235-46. [DOI: 10.1111/j.1365-2648.2011.05823.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Farmer J, Currie M, Hyman J, West C, Arnott N. Evaluation of physician assistants in National Health Service Scotland. Scott Med J 2011; 56:130-4. [DOI: 10.1258/smj.2011.011109] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Physician assistants (PAs) have medical training and work supervised by a doctor. In 2006-2008 the Scottish Government piloted use of USA-trained PAs. The aim of the paper is to evaluate the impact and contribution made by PAs to delivering effective health care in National Health Service (NHS) Scotland. Mixed methods, longitudinally, including interviews, feedback forms and activity data collection. Data analysis used nVivo, SPSS and Excel. Participants were 15 USA-trained PAs, medical supervisors and team members, 20 patients, four NHS senior managers and three trade union representatives. Settings were four Scottish NHS Boards where PAs worked in primary care, out of hours clinics, emergency medicine, intermediate care and orthopaedics. Two minor patient safety issues arose. Patients were satisfied with PAs. Scope of practice did not replicate US working. Inability to prescribe was a hindrance. PAs tended to have longer consultations, but provided continuity and an educational resource. They were assessed to be mid-level practitioners approximating to nurse practitioner or generalist doctor. Valued features were generalism, medical background, confidence differential diagnosis and communication. Interviewees suggested PAs could fulfil roles currently filled by medical staff, potentially saving resources. In conclusion, there is potential for PAs to fulfil distinctive mid-level roles in the Scottish NHS adding value in continuity, communication and medical approach.
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Affiliation(s)
- J Farmer
- Chair of Rural Health Policy & Management, Centre for Rural Health, UHI Millennium Institute, The Centre for Health Science, Perth Road, Inverness IV2 3JH, UK
| | - M Currie
- Research Fellow, Centre for Rural Health, UHI Millennium Institute, The Centre for Health Science, Perth Road, Inverness IV2 3JH, UK
| | - J Hyman
- University of Aberdeen Business School, Edward Wright Building, Dunbar Street, Aberdeen, UK
| | - C West
- Clinical Services Manager (Primary Care), NHS Highland, Argyll and Bute Community Health Partnership, Oban, UK
| | - N Arnott
- Tweeddale Medical Practice, Fort William Health Centre, Camaghael, Fort William, UK
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Drennan V, Levenson R, Halter M, Tye C. Physician assistants in English general practice: a qualitative study of employers' viewpoints. J Health Serv Res Policy 2011; 16:75-80. [PMID: 21389060 DOI: 10.1258/jhsrp.2010.010061] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Effective use of staff is a major aim in all health-care systems both to maximize their impact and to minimize costs. In England, a few general practitioners (GPs) have been recruiting physician assistants (PAs) to work in their practices, independent of any pilot schemes. Our objective was to study the motivation of GPs and practice managers who employed PAs and to understand the factors that sustained their employment. METHODS A qualitative study using semi-structured interviews, analysed thematically, was carried out with 13 GPs and three practice managers from 15 general practices employing PAs in five areas of England. RESULTS All practices were employing USA-trained PAs. Motivating factors for their employment included increasing the general practice capacity to manage patient demand within government targets for access, broaden the skill-mix in the practice team and financial considerations. The issues that needed to be taken into account in employing PAs included: the requirement for medical supervision; the PAs current lack of a regulatory framework and prescribing authority; and some patients' lack of familiarity with the concept of the PA. CONCLUSIONS General practice employers view PAs as a positive addition to a mixed skill team for meeting patient demand within a practice's finances. There is a need to develop stronger governance and regulatory frameworks for this emerging profession.
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Affiliation(s)
- Vari Drennan
- Faculty of Health & Social Care Sciences, Kingston University & St George's, University of London, London, UK.
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45
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Freed GL, Dunham KM, Moote MJ, Lamarand KE. Pediatric physician assistants: distribution and scope of practice. Pediatrics 2010; 126:851-5. [PMID: 20956413 DOI: 10.1542/peds.2010-1586] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited. OBJECTIVE To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice. METHODS Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties. RESULTS Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings. CONCLUSIONS PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.
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Affiliation(s)
- Gary L Freed
- University of Michigan, School of Public Health, Child Health Evaluation and Research (CHEAR) Unit, 300 North Ingalls Building, Ann Arbor, MI 48109-0456, USA.
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Roblin DW, Howard DH, Junling Ren, Becker ER. An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries. Med Care Res Rev 2010; 68:177-201. [PMID: 20829237 DOI: 10.1177/1077558710374619] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In service industries other than health care, unit employees who report a favorable service climate--characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative--have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO's 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.
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Naylor MD, Kurtzman ET. The Role Of Nurse Practitioners In Reinventing Primary Care. Health Aff (Millwood) 2010; 29:893-9. [DOI: 10.1377/hlthaff.2010.0440] [Citation(s) in RCA: 209] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mary D. Naylor
- Mary D. Naylor ( ) is the Marian S. Ware Professor of Gerontology and director of the NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, in Philadelphia
| | - Ellen T. Kurtzman
- Ellen T. Kurtzman is an assistant research professor in the Department of Nursing Education, George Washington University, in Washington, D.C
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Chapman SA, Wides CD, Spetz J. Payment regulations for advanced practice nurses: implications for primary care. Policy Polit Nurs Pract 2010; 11:89-98. [PMID: 20834022 DOI: 10.1177/1527154410382458] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The shortage of primary care providers (PCPs) in the United States may be worsened with health reform if more individuals receive health insurance coverage. Previous research suggests that Advanced Practice Registered Nurses (APRNs) can provide as high quality care and achieve the same health outcomes as physicians. However, APRNs are usually reimbursed at lower rates than physicians by both Medicare and Medicaid. Private health insurance regulations and Any Willing Provider laws vary from state to state but in general do little to facilitate the ability of APRNs to be reimbursed for their services or to be credentialed as PCPs. To maximize the utilization of APRNs as PCPs, the payment system should be remodeled. A clear regulatory framework and payment rationale are needed along with data on the type and complexity of care provided by various practitioners to increase efficiencies and improve access to health care.
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Chung K, Yang D, Lee JH. Determinants of primary care physicians' referral pattern: a structural equation model approach. INTERNATIONAL JOURNAL OF PUBLIC POLICY 2010; 5:259-271. [PMID: 20351790 PMCID: PMC2846366 DOI: 10.1504/ijpp.2010.030607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This study examines patient referrals by primary care physicians (PCP) with nurse practitioners and physician assistants (NP-PA) in their medical practices as compared to practices without them. The study uses data from the Robert Wood Johnson Foundation community tracking study (CTS) Physician Survey, Round I (1996-97) and II (1998-99). Structural equations with binary dependent variables were used to examine the links among managed care, the use of NP-PA, the complexity of patient's conditions, and the number of referrals. PCP's with NP-PA were found to have a greater likelihood of treating patients with complex conditions instead of referring them to specialists. Managed care related variables (i.e., large group practice/HMO, the percentage of patients for whom PCPs acted as gatekeepers, and the percentage of managed care revenue from capitated/prepaid contracts) affected PCP' patient referrals, but only through the increased use of NP-PA. PCP's with NP-PA were also found to provide appropriate care to the complex patients. These findings indicate that NP-PA enable PCP to concentrate on patients with more complex conditions thus reducing the number of referrals. In addition, NP-PA is found to affect the gatekeeper role of PCPs.
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Affiliation(s)
- Kyusuk Chung
- Department of Health Administration, College of Health Professions, Governors State University, University Park, IL 60466-097, USA, , E-mail:
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Everett CM, Schumacher JR, Wright A, Smith MA. Physician assistants and nurse practitioners as a usual source of care. J Rural Health 2009; 25:407-14. [PMID: 19780923 DOI: 10.1111/j.1748-0361.2009.00252.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. METHODS Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). FINDINGS Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (beta=-0.22, 95% CI =-0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. CONCLUSIONS Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.
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Affiliation(s)
- Christine M Everett
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA.
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