Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review

Introduction

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD.

Methods

A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035).

Results

In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility.

Conclusion

The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Outcomes of Hematuria Evaluation by Advanced Practice Providers and Urologists

OBJECTIVE

To examine the quality and costs of care for patients evaluated for hematuria by urologic advanced practice providers (APPs) and urologists. The roles of APPs in urology are growing, but their clinical and financial outcomes compared to urologists are not well understood.

METHODS

We conducted a retrospective cohort study of commercially insured patients using data from 2014 to 2020. We included adult beneficiaries with a diagnosis code for hematuria and an initial outpatient evaluation and management visit with a urologic APP or urologist. We assessed receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within 6 months of the initial visit. Secondary outcomes included the time until each of these outcomes occurred and the out-of-pocket spending and total payments.

RESULTS

We identified 59,923 patients who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio [OR] 0.93, 95% confidence interval [95% CI] 0.54-0.72, P < .001), imaging studies (OR 0.79, 95% CI 0.69-0.91, P < .001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, P = .02). Visits with urologic physician assistants were associated with 11% greater out-of-pocket payments (incident risk ratio 1.11, CI 1.01-1.22, P = .02) and 14% greater total payments (incident risk ratio 1.14, CI 1.04-1.25, P = .004).

CONCLUSION

There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study, and specialty-specific training for APPs should be considered.

Effects of Advanced Practice Providers on Single-specialty Surgical Practice

OBJECTIVE

To assess the effects of adding advanced practice providers to surgical practices on surgical complications, readmissions, mortality, episode spending, length of stay, and access to care.

SUMMARY BACKGROUND DATA

There has been substantial growth in the number of nurse practitioners and physician assistants (ie, advanced practice providers) in the United States. The extent to which advanced practice providers have been integrated into surgical practice, and their impact on surgical outcomes and access is unclear.

METHODS

Using a 20% sample of national Medicare claims, we performed a retrospective cohort study of fee-for-service beneficiaries undergoing one of 4 major procedures (coronary artery bypass graft, colectomy, major joint replacement, and cystectomy) between 2010 and 2016. We limited our study population for each procedure to patients treated by single-specialty surgical groups to ensure that the advanced practice providers have direct interactions with its surgeons and patients. All outcomes were measured at the practice level for the year before and the year after the addition of the first advanced practice provider. Outcomes included: complications, readmission, mortality, episode payments, length of stay. Models were adjusted for age, race, sex, comorbidity, socioeconomic class and procedure type. Secondary outcome: practice-level office visits by surgical group type.

RESULTS

The number of advanced practice providers increased by 13%, from 6713 to 7596 between 2010 and 2016. The largest relative increases occurred in general (46.9%) and urologic (27.6%) surgical practices. The year after an advanced practice provider was added to a surgical practice, the odds of complications were 17% and 16% lower at 30- and 90-days postprocedure, respectively. Additionally, 90-day readmissions were 18% less likely and length of stay was 0.33 days shorter (a 7.1% reduction). Average 30-day and90-day episode spending was $1294.73 and $1427.76 lower, respectively ( P < 0.001). General surgical, orthopedic, and urology practices realized increases of 49.0 (95% CI 13.5-84.5), 112.0 (95% CI 83.0-140.5), and 205.0 (95% CI 117.5-292.0) in-office visits per surgeon, respectively.

CONCLUSIONS

The addition of advanced practice providers to single-specialty surgical groups is associated with improvements in surgical outcomes and access. Future work should clarify the mechanisms by which advanced practice providers within surgical practices contribute to health outcomes to identify best practices for deployment.

Impact of State Nurse Practitioner Regulations on Potentially Inappropriate Medication Prescribing Between Physicians and Nurse Practitioners: A National Study in the United States

BACKGROUND

The American Geriatrics Society regularly updates the Beers Criteria for Potentially Inappropriate Medication (PIM) to improve prescribing safety.

PURPOSE

This study assessed the impact of nurse practitioner (NP) practices on PIM prescribing across states in the United States and compared the change in PIM prescribing rates between 2016 and 2018.

METHODS

We used data from a random selection of 20% of Medicare beneficiaries (66 years or older) from 2015 to 2018 to perform multilevel logistic regression. A PIM prescription was classified as initial or refill on the basis of medication history 1 year before a visit. PIM use after an outpatient visit was the primary study outcome.

RESULTS

We included 9 000 224 visits in 2016 and 9 310 261 in 2018. The PIM prescription rate was lower in states with full NP practice and lower among NPs than among physicians; these rates for both physicians and NPs decreased from 2016 to 2018.

CONCLUSIONS

Changes could be due to individual state practices.

B·RIGHT: usability and satisfaction with a mobile app for self-managing emotional crises in patients with borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotional crises. To date, crisis interventions for BPD have been conducted via telephone calls and emergency units, which are associated with an extra amount of resources. The aim of this research was to test the usability and satisfaction with a psychotherapeutic mobile app for self-managing crises in BPD.

METHOD

The B·RIGHT app was designed based on Artificial Intelligence psychotherapeutic algorithms. Usability and satisfaction with the app were assessed in 25 outpatients diagnosed with BPD (84% female, mean age = 35.80 years) using the System Usability Scale (SUS) and other questionnaires. Clinical features were assessed using the Borderline Symptom List, the Difficulties in Emotion Regulation Scale and Beck's Depression Inventory.

RESULTS

Patients with BPD considered the app user-friendly (mean total score = 4.03) and highly satisfactory (mean total score = 4.02), resulting in a positive user experience (mean total score = 4.09). Total usability was negatively associated with age (r = -.44), positively associated with educational level (rho = .47) and with overall emotion dysregulation (r = .51), and negatively associated with depression severity (r = -.47).

CONCLUSIONS

The usability and satisfaction testing of the B·RIGHT app showed promising findings, which warrant further research in order to validate its effectiveness.

Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

RESEARCH OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Are Online Reviews of Physicians Reliable Indicators of Clinical Outcomes? A Focus on Chronic Disease Management

Are Online Reviews of Physicians Reliable Indicators of Clinical Outcomes? A Focus on Chronic Disease Management

Integrated older people care and advanced practice nursing: an evidence-based review

AIM

To critically appraise and synthesize evidence of integrated care stemming from advanced practice nursing in elderly primary care settings throughout the United States and Thailand.

BACKGROUND

Advanced practice nurses are key to accelerating integrated elderly care in the community. Yet, their scope and capacity vary greatly across countries, making impact measurement highly challenging.

METHODS

A systematic search of PubMed, CINAHL, Scopus and ThaiJo databases was performed. Full-text articles in English or Thai language were reviewed using an inductive thematic approach from the integrated people-centred Health Services framework, adopted by the World Health Organization.

RESULTS

A total of 42 articles were appraised according to framework strategies: (1) people and community empowerment/engagement; (2) governance and accountability strengthening; (3) model of care reorientation; (4) service coordination; and (5) enabling environment creation. Collaborative roles and empowerment of older people were associated with higher quality of care. Thai nurses empowered individuals through community networks and resources, incorporating care models (strategy 1). In contrast, US nurses adopted a quality improvement and safety approach, incorporating technology into nursing interventions (strategy 5).

CONCLUSION

Advanced practice nurses employ an array of strategies and approaches in caring for older people. Although their role varies from mostly substitute (US) to supplemental (Thailand), nurses in both countries contribute towards integrated person-centred care.

IMPLICATION FOR NURSING PRACTICE AND NURSING POLICY

Preparing advanced practice nurses to work in the community is a prerequisite for meeting ageing population health needs in a sustainable manner. Education, professional development and leadership training opportunities should focus on capacity building in: a) strengthening mutual accountability, b) reorienting the work environment through innovative care models and c) coordinating services through partnerships to achieve universal health and ensure healthy ageing.

Reducing COPD Readmissions: Strategies for the Pulmonologist to Improve Outcomes

Hospitalizations for patients with acute exacerbations of COPD are associated with several adverse patient outcomes as well as with significant health-care costs. Despite many interventions targeted at reducing readmissions following an initial hospitalization, there are few strategies that have been consistently associated with reductions in this outcome. Despite the lack of consensus as to the best strategies to deploy to reduce readmissions related to acute exacerbations of COPD, efforts must continue to focus on determining the best approaches for this population. These tactics will need to be cost-effective for payers while not being cost-prohibitive for providers. In addition, these interventions will need to be relatively easy to institute while not being overbearing for patients or providers. Larger systems with their greater financial resources will likely find success with technology and data-driven comprehensive programs; independent hospitals and practices are more likely to succeed with less resource-intensive interventions such as early postdischarge follow-up, coaching, action plans, self-management education, and pulmonary rehabilitation. Choosing the right interventions that will utilize financial and human resources in a cost-effective manner, while tailoring the approaches to meet the needs of a specific patient group, will be of key importance.

Evaluation of the primary care for chronic diseases in the high coverage context of the Family Health Strategy

BACKGROUND

This cross-sectional study evaluated the adequacy of the Family Health Strategy for the primary care model for chronic noncommunicable diseases and the changes that occurred between the two cycles of external evaluations of the National Program for Improving Access and Quality of Primary Care, which took place in 2012 and 2014, in the higher coverage context of the Family Health Strategy of Brazil, in the state of Tocantins, Brazil.

METHODS

The data source contained information on the infrastructure of the 233 Primary Health Units and on the work process of 266 health teams. The Principal Component Analysis for Categorical Data technique and the McNemar chi-squared statistical test for comparing paired samples were used, and a significance level of 5% with a 95% Confidence Interval was used.

RESULTS

The analysis identified a low proportion of dispensing of medications for the treatment of chronic disease in both cycles. There was a significant increase in seasonal influenza vaccination, in the number of sterilization, procedure, dressings and inhalation rooms. There was a small but significant reduction in the materials for cervical cancer screening, although they are available in almost 90.0% of the PHUs. More than 70.0% of the health teams carried out additional health education activities, encouraged physical activity, registered schoolchildren with health needs for monitoring, evaluated user satisfaction and user referral.

CONCLUSIONS

The findings of this study highlighted the improvement of the structure of the Primary Health Units, but identified a low provision of medicines to treat chronic diseases. The health promotion was performed as the main work process tool of family health teams, but it was little focused on intersectoral actions and on actions with the population in the area or on the empowerment of users through self-management support for chronic diseases. Furthermore, it is critical that the Family Health Strategy in Tocantins be organized and focused on the care of chronic diseases to improve and adapt itself to a primary chronic care model.

Insights about the economic impact of chronic obstructive pulmonary disease readmissions post implementation of the hospital readmission reduction program

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) affects over 12 million adults in the United States and is the third leading cause of 30-day readmissions. COPD is costly with almost $50 billion in direct costs annually. Total COPD costs can be up to double the identified direct costs because of comorbid disease and numerous indirect costs such as absenteeism. Acute exacerbations of COPD (AECOPD) are responsible for up to 70% of COPD-related healthcare costs; hospital readmissions alone account for over $15 billion annually. In this review, we aim to describe insights about the economic impact of COPD readmissions based on articles published over the last 18 months.

RECENT FINDINGS

Interventions aimed at reducing readmission, particularly those using interdisciplinary teams with bundled care interventions, were uniformly successful at improving the quality of care provided and demonstrating improved process measures. However, success at reducing readmissions and cost savings based on these interventions varied across the studies.

SUMMARY

The literature to date points to factors and conditions that may place patients at higher risk of readmissions and may lead to higher costs. Interventions aimed at reducing readmissions after index admissions for AECOPD have demonstrated variable results. Most interventions did not reflect cost-based analyses.

The viability and necessity of APRN-led care models in the clinical management of haemophilia and other inherited bleeding and clotting disorders

A growing and ageing haemophilia treatment centre (HTC) population, as well as a glaring shortage of adult haematologists available for the clinical management of persons with haemophilia (PWH), has resulted in significant care gaps in the United States. In response, various advanced practice registered nurse (APRN)-based models have been adopted across the country to counteract a deficit in haematologist resources for adult PWH. These models in the management of PWH have demonstrated competency and efficiency in the care of patients with haemophilia, offering a viable solution in areas where haematologist resources are limited and assure quality care provision, most notably in rural areas. The available literature indicates equivalence in terms of clinical outcomes, patient satisfaction and elements of healthcare service utilization. With continued support in current clinical guidelines and institutional contributions in the form of residency and fellowship programmes, the robust successes of APRN models for the clinical management of PWH can be maintained and expanded well into the foreseeable future.

Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models

BACKGROUND

Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs).

METHODS AND RESULTS

We used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32-1.37; odds ratio  1.32, 95% confidence interval 1.30-1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model.

CONCLUSION

The delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.