New chronic disease medication prescribing by nurse practitioners, physician assistants, and primary care physicians: a cohort study

Prescribing Alzheimer's Disease treatments by provider type and geographic region: a comparison among physicians, nurse practitioners, and physician assistants

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.

Provider and Patient-panel Characteristics Associated With Initial Adoption and Sustained Prescribing of Medication for Opioid Use Disorder

OBJECTIVES

Limited information is available regarding provider- and patient panel-level factors associated with primary care provider (PCP) adoption/prescribing of medication for opioid use disorder (MOUD).

METHODS

We assessed a retrospective cohort from 2015 to 2018 within the Pennsylvania Medicaid Program. Participants included PCPs who were Medicaid providers, with no history of MOUD provision, and who treated ≥10 Medicaid enrollees annually. We assessed initial MOUD adoption, defined as an index buprenorphine/buprenorphine-naloxone or oral/extended release naltrexone fill and sustained prescribing, defined as ≥1 MOUD prescription(s) for 3 consecutive quarters from the PCP. Independent variables included provider- and patient panel-level characteristics.

RESULTS

We identified 113 rural and 782 urban PCPs who engaged in initial adoption and 36 rural and 288 urban PCPs who engaged in sustained prescribing. Rural/urban PCPs who issued increasingly larger numbers of antidepressant and antipsychotic medication prescriptions had greater odds of initial adoption and sustained prescribing (P < 0.05) compared to those that did not prescribe these medications. Further, each additional patient out of 100 with opioid use disorder diagnosed before MOUD adoption increased the adjusted odds for initial adoption 2% to 4% (95% confidence interval [CI] = 1.01-1.08) and sustained prescribing by 4% to 7% (95% CI = 1.01-1.08). New Medicaid providers in rural areas were 2.52 (95% CI = 1.04-6.11) and in urban areas were 2.66 (95% CI = 1.94, 3.64) more likely to engage in initial MOUD adoption compared to established PCPs.

CONCLUSIONS

MOUD prescribing adoption was concentrated among PCPs prescribing mental health medications, caring for those with OUD, and new Medicaid providers. These results should be leveraged to test/implement interventions targeting MOUD adoption among PCPs.

FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality

BACKGROUND

Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.

OBJECTIVE

To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.

DESIGN

We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018.

PARTICIPANTS

A total of 2190 medical practices with at least three adult primary care physicians.

MAIN MEASURES

Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.

KEY RESULTS

FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001).

CONCLUSION

FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.

Avoiding Medicaid: Characteristics Of Primary Care Practices With No Medicaid Revenue

Primary care access for Medicaid patients is an ongoing area of concern. Most studies of providers' participation in Medicaid have focused on factors associated with the Medicaid program, such as reimbursement rates. Few studies have examined the characteristics of primary care practices associated with Medicaid participation. We used a nationally representative survey of primary care practices to compare practices with no, low, and high Medicaid revenue. Seventeen percent of practices received no Medicaid revenue; 38 percent and 45 percent were categorized as receiving low and high Medicaid revenue, respectively. Practices with no Medicaid revenue were more often small, independent, and located in urban areas with higher household income. These practices also have lower population health capabilities.

Utilization of High-Intensity Statins in Patients at Risk for Cardiovascular Events: A National Cross-Sectional Study

BACKGROUND

The 2013 American College of Cardiology/American Heart Association cholesterol guidelines, which identified four groups of patients at risk for atherosclerotic cardiovascular disease events, departed from the target-based approach to managing cholesterol. The impact of these guidelines on high-intensity statin use across the United States is unclear.

STUDY QUESTION

The primary objective was to evaluate the rate of high-intensity potential (HIP) statin use before and after the 2013 guidelines. The secondary objective was to identify predictors of HIP statin use within the study population.

STUDY DESIGN

A national cross-sectional study was conducted using data from the National Ambulatory Medical Care Survey. Office visits involving patients aged 21-75 years where criteria for HIP statin therapy were met were included. Visits involving pregnant patients were excluded.

MEASURES AND OUTCOMES

Prescribing trends of HIP statins were measured from National Ambulatory Medical Care Survey data before and after the 2013 guidelines. Multivariate logistic regression identified variables associated with prescribing HIP statins.

RESULTS

A total of 48,884 visits were included, representing more than 940 million office visits nationally. HIP statins were listed in 9.5% and 16.5% of visits before and after 2013, respectively (odds ratio [OR] 1.88; 95% confidence interval [CI] 1.62-2.20). The strongest predictors of HIP statin use were antihypertensive use (OR 5.38, 95% CI 4.67-6.20), comorbid hyperlipidemia (OR 2.93, 95% CI 2.62-3.29), Black race (OR 0.63, 95% CI 0.49-0.81), and Hispanic ethnicity (OR 0.65, 95% CI 0.52-0.80).

CONCLUSIONS

Prescribing rates for HIP statins increased after the release of the 2013 guidelines. The prescribing rates were lower than expected, especially in Black and Hispanic patients. These observations signify opportunities to improve the quality of care for patients who are at risk for atherosclerotic cardiovascular disease events in the United States.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

BACKGROUND

General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs.

METHODS

According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed.

RESULTS

Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases.

CONCLUSION

Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.

Nurse practitioners' recommendations for pharmacotherapy in the management of adolescent concussion

BACKGROUND AND PURPOSE

Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion.

METHODS

This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described.

CONCLUSIONS

In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality.

IMPLICATIONS FOR PRACTICE

Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.

Management of venous thromboembolism with non-vitamin K oral anticoagulants: A review for nurse practitioners and pharmacists

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE), comprising deep-vein thrombosis and pulmonary embolism, is associated with significant morbidity and mortality. Non-vitamin K oral anticoagulants (NOACs), including apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban, are as effective and safe as vitamin K antagonists (VKAs) for primary prophylaxis, treatment, and/or secondary prevention of VTE and present significant advantages in convenience of use. This review provides guidance to nurse practitioners (NPs) and pharmacists on NOAC usage for the management of VTE and examines how traditional anticoagulation clinics can adapt to cater to patients on NOACs.

METHODS

A review of the scientific literature pertaining to treatment guideline recommendations, large randomized clinical trials, and real-world evidence studies related to VTE management was conducted.

CONCLUSIONS

With current data suggesting that NOACs may present as better alternatives over VKAs for the management of VTE, comprehensively educating NPs and pharmacists can help incorporate these agents in their clinical practice.

IMPLICATIONS FOR PRACTICE

Repurposing anticoagulation clinics, led by well-informed NPs and pharmacists, will allow effective integration and optimal management of patients with VTE taking NOACs as well as those taking VKAs.