Primary care: proposed solutions to the physician shortage without training more physicians

Describing the Physician Associate Clinical Training Site Compensation Market

INTRODUCTION

Inadequate clinical training site availability may inhibit physician assistant/associate (PA), advanced practice nursing (APN), and physician workforce growth. Educational institutions increasingly incentivize clinical training sites with financial compensation, with potential implications for educational costs and enrollment. This study investigated compensation trends among PA programs.

METHODS

Data from the 2013 to 2019 PA Education Association Program Reports were examined. Multivariate logistic and linear regressions were estimated to identify the influence of PA program characteristics on clinical training site compensation. The effect of compensation on program enrollment was determined with a difference-in-differences estimator.

RESULTS

Physician assistant/associate programs collectively paid nearly $19 million to clinical training sites in 2019. The percentage of programs that offer financial incentives increased from 22.2% in 2013 to 52.3% in 2019. Over this time, public institutions affiliated with academic health centers (AHCs) were least likely to offer compensation. Higher compensation rates were observed in Census divisions with greater number of programs, and programs located in New England were the most likely to offer compensation. Offering compensation did not influence growth in programs' enrollment.

DISCUSSION

Compensation trends highlight increasing demand for PA clinical training sites, especially in areas with greater regional competition. Compensation is primarily driven by private institutions unaffiliated with AHCs. Programs likely offer compensation to maintain, rather than grow, enrollment. Additional investigation should incorporate medical school and APN program data to more fully examine the impact of these costs on learners, institutions, and the health care workforce.

Assessing the effectiveness of "BETTER Women", a community-based, primary care-linked peer health coaching programme for chronic disease prevention: protocol for a pragmatic, wait-list controlled, type 1 hybrid effectiveness-implementation trial

INTRODUCTION

The Building on Existing Tools to Improve Cancer and Chronic Disease Prevention and Screening in Primary Care (BETTER) programme trains allied health professionals working in primary care settings to develop personalised chronic disease 'prevention prescriptions' with patients. However, maintenance of health behaviour changes is difficult without ongoing support. Sustainable options to enhance the BETTER programme and ensure accessibility to underserved populations are needed. We designed the BETTER Women programme, which uses a digital app to match patients with a trained peer health coach (PHC) who provides ongoing support for health behaviour change after receipt of a BETTER prevention prescription in primary care.

METHODS AND ANALYSIS

We will conduct a type 1 hybrid implementation-effectiveness patient-randomised trial. Interested women aged 40-68 years will be recruited from three large, sociodemographically distinct primary care clinics (urban, suburban and rural). Patients will be randomised 1:1 to intervention or wait-list control after receipt of their BETTER prevention prescription. We will aim to recruit 204 patients per group (408 total). Effectiveness will be assessed by the primary outcome of targeted behaviours achieved for each participant at 6 months, consisting of three cancer screening tests (cervical, breast and colorectal) and four behavioural determinants of cancer and chronic disease (diet, smoking, alcohol use and physical activity). Data will be collected through patient survey and clinical chart review, measured at 3, 6 and 12 months. Implementation outcomes will be assessed through patient surveys and interviews with patients, peer health coaches and healthcare providers. An embedded economic evaluation will examine cost per quality-adjusted life-year and per additional health behavioural targets achieved.

ETHICS AND DISSEMINATION

This study has been approved by Women's College Hospital Research Ethics Board (REB), the Royal Victoria Regional Health Centre REB and the University of Toronto REB. All participants will provide informed consent prior to enrolment. Participation is voluntary and withdrawal will have no impact on the usual care received from their primary care provider. The results of this trial will be published in peer-reviewed journals and shared via conference presentations. Deidentified datasets will be shared on request, after publication of results.

TRIAL REGISTRATION NUMBER

NCT04746859.

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

OBJECTIVE

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

DESIGN

A retrospective register-based follow-up cohort study.

SETTING

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

SUBJECTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey

BACKGROUND

Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload.

OBJECTIVES

This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic.

DESIGN

Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936).

RESULTS

Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic.

CONCLUSIONS

Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access.

OBJECTIVE

To evaluate PC wait times before and after CRH implementation.

DESIGN

Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods.

PARTICIPANTS

Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics.

MAIN MEASURES

Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations.

KEY RESULTS

PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time.

CONCLUSIONS

In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.

Addressing the workforce crisis in (rural) social care: A scoping review

BACKGROUND

This scoping review identifies strategies potentially addressing the 'workforce crisis' in rural social care. The increasing global demand for social care has been coupled with widely recognised challenges in recruiting and retaining sufficient staff to provide this care. While the social care workforce crisis is a global phenomenon, it is particularly acute in rural areas.

METHODS

The review identified 75 papers which (i) had been published since 2017, (ii) were peer reviewed, (iii) concerned social care, (iv) were relevant to rural settings, (v) referenced workforce shortages, and (vi) made recommendations for ways to address those shortages. Thematic synthesis was used to derive three analytical themes with a combined 17 sub-themes applying to recommended strategies and evidence supporting those strategies.

RESULTS

The most common strategies for addressing social care workforce shortages were to improve recruitment and retention ('recruit and retain') processes without materially changing the workforce composition or service models. Further strategies involved 'revitalising' the social care workforce through redeploying existing staff or identifying new sources of labour. A small number of strategies involved 're-thinking' social care service models more fundamentally. Very few papers specifically considered how these strategies might apply to rural contexts, and evidence for the effectiveness of strategies was sparse.

CONCLUSION

The review identifies a significant gap in the literature in relation to workforce innovation and placed-based studies in rural social care systems. It is unlikely that the social care workforce crisis can be addressed through continuing attempts to recruit and retain workers within existing service models.

Transforming health care systems towards high-performance organizations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain)

BACKGROUND

The COVID-19 pandemic is one of the worst health catastrophes of the last century, which caused severe economic, political, and social consequences worldwide. Despite these devastating consequences, lessons learned provide a great opportunity that can drive the reform of health systems to become high-performing, effective, equitable, accessible, and sustainable organisations. This work identifies areas in which changes must be encouraged that will enable health systems to deal effectively with current and future challenges, beyond COVID-19.

METHODS

A realist design was chosen, based on qualitative data collection techniques, content analysis and triangulation to identify key domains of organizational interventions behind the changes implemented to react to the COVID-19 pandemic in the Basque Country. Twenty key informants were used as an expert source of information. Thematic analysis was done using the Framework Method.

RESULTS

The analysis of the interviews resulted in the identification of 116 codes, which were reviewed and agreed upon by the researchers. Following the process of methodological analysis, these codes were grouped into domains: seven themes and 23 sub-themes. Specifically, the themes are: responsiveness, telehealth, integration, knowledge management, professional roles, digitisation, and organisational communication. The detailed description of each theme and subtheme is presented.

CONCLUSIONS

The findings of this work pretend to guide the transformation of health systems into organisations that can improve the health of their populations and provide high quality care. Such a multidimensional and comprehensive reform encompasses both strategic and operational actions in diverse areas and requires a broad and sustained political, technical, and financial commitment.

Navigating the doctor-patient-AI relationship - a mixed-methods study of physician attitudes toward artificial intelligence in primary care

BACKGROUND

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

METHODS

From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.

RESULTS

Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).

CONCLUSION

Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

Managing common ambulatory conditions: Exploring clinical decision making performance between pharmacists and family physicians

Background

Prescribing is part of the expanded scope of practice for pharmacists in Alberta, Canada. Given these responsibilities, clinical decision making (the outcome from the diagnostic and therapeutic decision making process) is an essential skill for pharmacists. The current study compared diagnostic and therapeutic decision-making between Additional Prescribing Authority (APA) pharmacists and family physicians using a set of common ambulatory clinical cases that both practitioners could encounter in the community as part of their daily practice.

Objectives

To explore clinical decision making performance and behaviors between APA pharmacists and family physicians during the assessment and prescribing of common ambulatory conditions.

Methods

Eight written ambulatory clinical cases were developed by a panel of experts in both family medicine and pharmacy that were commonly encountered in both professions' daily practice. Participating APA pharmacists and family physicians reviewed the cases and responded with likely diagnoses, recommended treatments, and reported confidence in therapeutic choices. The responses of 18 APA pharmacists and 9 family physicians in community practices were analyzed.

Results

There were no significant differences in diagnostic accuracy, therapeutic accuracy, confidence in diagnostic choices, and confidence in therapeutic choices between APA pharmacists and family physicians to these common ambulatory presentations.

Conclusions

This study provides preliminary insights regarding the capabilities of pharmacists in the assessment of common ambulatory community conditions and suggests that APA pharmacists are making similar diagnostic and therapeutic decisions to family physicians. Future research could focus on examining the performance of pharmacists trained in different pharmacy education models, as well as their ability to provide clinical assessment in other specialties, or in more uncommon clinical scenarios.

Standardising the role of a digital navigator in behavioural health: a systematic review

As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.

Using machine learning to forecast symptom changes among subclinical depression patients receiving stepped care or usual care

BACKGROUND

Subclinical depression (SD) is a mental health disorder characterized by minor depressive symptoms. Most SD patients are treated in the primary practice, but many respond poorly to treatment at the expense of provider resources. Stepped care approaches are appealing for tiering SD care to efficiently allocate scarce resources while jointly optimizing patient outcomes. However, stepped care can be time inefficient, as some persons may respond poorly and be forced to suffer with their symptoms for prolonged periods. Machine learning can offer insight into optimal treatment paths and inform clinical recommendations for incident patients.

METHODS

As part of the Step-Dep trial, participants with SD were randomized to receive stepped care (N=96) or usual care (N=140). Machine learning was used to predict changes in depressive symptoms every three months over a year for each treatment group.

RESULTS

Tree-based models were effective in predicting PHQ-9 changes among patients who received stepped care (r=0.35-0.46, MAE=0.14-0.17) and usual care (r=0.34-0.49, MAE=0.15-0.18). Patients who received stepped care were more likely to reduce PHQ-9 scores if they had high PHQ-9 but low HADS-A scores at baseline, a low number of chronic illnesses, and an internal locus of control.

LIMITATIONS

Models may suffer from potential overfitting due to sample size limitations.

CONCLUSION

Our findings demonstrate the promise of machine learning for predicting changes in depressive symptoms for SD patients receiving different treatments. Trained models can intake incident patient information and predict outcomes to inform personalized care.

Examining supporting and constraining factors of physicians' acceptance of telemedical online consultations: a survey study

As healthcare demands exceed outpatient physicians' capacities, telemedicine holds far-reaching potential for both physicians and patients. It is crucial to holistically analyze physicians' acceptance of telemedical applications, such as online consultations. This study seeks to identify supporting and constraining factors that influence outpatient physicians' acceptance of telemedicine.We develop a model based on the unified theory of acceptance and use of technology (UTAUT). To empirically examine our research model, we conducted a survey among German physicians (n = 127) in 2018-2019. We used the partial least squares (PLS) modeling approach to test our model, including a mediation analysis. The results indicate that performance expectancy (β = .397, P < .001), effort expectancy (β = .134, P = .03), and social influence (β = .337, P < .001) strongly impact the intention to conduct online consultations and explain 55% of its variance. Structural conditions regarding data security comprise a key antecedent, associating with performance expectancy (β = .193, P < .001) and effort expectancy (β = .295, P < .001). Regarding potential barriers to usage intentions, we find that IT anxiety predicts performance (β = -.342, P < .001) and effort expectancy (β = -.364, P < .001), while performance expectancy fully mediates (βdirect = .022, P = .71; βindirect = -.138, P < .001) the direct relationship between IT anxiety and the intention to use telemedical applications.This research provides explanations for physicians' behavioral intention to use online consultations, underlining UTAUT's applicability in healthcare contexts. To boost acceptance, social influences, such as personal connections and networking are vital, as colleagues can serve as multipliers to reach convergence on online consultations among peers. To overcome physicians' IT anxiety, training, demonstrations, knowledge sharing, and management incentives are recommended. Furthermore, regulations and standards to build trust in the compliance of online consultations with data protection guidelines need reinforcement from policymakers and hospital management alike.

Estimating the Primary Care Workforce for Medicare Beneficiaries Using an Activity-Based Approach

BACKGROUND

The enumeration of the primary care workforce relies on potentially inaccurate specialty designations sourced from licensure registries and clinician surveys.

OBJECTIVE

To use an activity-based measure of primary care to estimate the number of physicians, nurse practitioners (NPs), and physician assistants (PAs) providing primary care to Medicare beneficiaries.

DESIGN

Observational study using Medicare fee-for-service (FFS) claims data.

SUBJECTS

All clinicians in the US billing Medicare in 2019 and their fee-for-service Medicare patients.

MAIN MEASURES

We construct three measures that together distinguish primary care from specialty clinicians: (1) presence of evaluation and management (E&M) services in a setting consistent with primary care, (2) the dispersion of clinical care across International Classification of Diseases-10 (ICD-10) chapters, and (3) the extent of provided services that are atypical of primary care (e.g., surgical procedure). We apply parameters to the measures to identify the clinicians likely providing primary care and compare the resulting classifications across provider type.

KEY RESULTS

Of physicians with at least 50 Medicare beneficiaries, 19-22% provide primary care. Of medical generalists (i.e., family medicine, internal medicine) with at least 50 beneficiaries, 61-68% provide primary care. We estimate that 40-45% of NPs and 27-30% of PAs meeting the panel size threshold are primary care providers in FFS Medicare.

CONCLUSIONS

Our findings suggest that based on a primary care practice style, the number of primary care physicians in FFS Medicare is likely smaller than conventional estimates. However, compared to prior estimates, the number of primary care NPs is larger and the number of PAs is similar.

Earnings, job satisfaction, and turnover of nurse practitioners across employment settings

Nurse practitioners (NPs) are an important part of the health care workforce. However, little information is available on NP earnings, job satisfaction, or turnover. National survey data from 2018 offer a pre-COVID-19 baseline for ongoing NP workforce monitoring. We found evidence that NPs earned approximately $92 500 annually, ranging from $82 800 in long-term care to $95 600 in hospital settings. Wages increased with tenure in the workforce and varied considerably by geography. Approximately 1 in 5 NPs switched jobs annually, with some net in-flow to ambulatory settings. Both NPs who left their position or considered leaving reported better pay and benefits, burnout, management role, stressful work environment, career advancement, and inadequate staffing as the primary explanations. These findings were augmented by analysis of 2012-2022 Bureau of Labor Statistics data that illustrated substantial growth in the NP workforce. Improving NP job satisfaction has the direct benefit of supporting a critical and growing segment of the health workforce; it has the additional benefit of reducing job turnover and the associated costs, potentially increasing earnings for NPs. Policies that improve working conditions for NPs in different employment settings will not just increase immediate job satisfaction but also ideally strengthen the longer-term labor market to improve patient outcomes.

Primary care provider perspectives on the role of community pharmacy in colorectal cancer screening: a qualitative study

BACKGROUND

The United States Preventive Services Task Force (USPSTF) lists 32 grade A or B recommended preventive services for non-pregnant United States (US) adults, including colorectal cancer screening (CRC). Little guidance is given on how to implement these services with consistency and fidelity in primary care. Given limited patient visit time and competing demands, primary care providers (PCPs) tend to prioritize a small subset of these recommendations. Completion rates of some of these services, including CRC screening, are suboptimal. Expanding delivery of preventive services to other healthcare providers, where possible, can improve access and uptake, particularly in medically underserved areas or populations. Fecal immunochemical testing (FIT) (at-home, stool-based testing) for CRC screening can be distributed and resulted without PCP involvement. Pharmacists have long delivered preventive services (e.g., influenza vaccination) and may be a good option for expanding CRC screening delivery using FIT, but it is not clear how PCPs would perceive this expansion.

METHODS

We used semi-structured interviews with PCPs in North Carolina and Washington state to assess perceptions and recommendations for a potential pharmacy-based FIT distribution program (PharmFIT™). Transcripts were coded and analyzed using a hybrid inductive-deductive content analysis guided by the Consolidated Framework for Implementation Research (CFIR) to elucidate potential multi-level facilitators of and barriers to implementation of PharmFIT™.

RESULTS

We completed 30 interviews with PCPs in North Carolina (N = 12) and Washington state (N = 18). PCPs in both states were largely accepting of PharmFIT™, with several important considerations. First, PCPs felt that pharmacists should receive appropriate training for identifying patients eligible and due for FIT screening. Second, a clear understanding of responsibility for tracking tests, communication, and, particularly, follow-up of positive test results should be established and followed. Finally, clear electronic workflows should be established for relay of test result information between the pharmacy and the primary care clinic.

CONCLUSION

If the conditions are met regarding pharmacist training, follow-up for positive FITs, and transfer of documentation, PCPs are likely to support PharmFIT™ as a way for their patients to obtain and complete CRC screening using FIT.

Characteristics, work environments, and rates of burnout and job dissatisfaction among registered nurses in primary care

BACKGROUND

Although more people than ever are seeking primary care, the ratio of primary care providers to the population continues to rapidly decline. As such, registered nurses (RNs) are taking on increasingly central roles in primary care delivery. Yet little is known about their characteristics, their work environments, and the extent to which they experience poor job outcomes such as nurse burnout.

PURPOSE

The purpose of this study was to examine the characteristics of the primary care RN workforce and analyze the association of the nurse work environment with job outcomes in primary care.

METHODS

Cross-sectional analysis of survey data representing N = 463 RNs who worked in 398 primary care practices, including primary care offices, community clinics, retail/urgent care clinics, and nurse-managed clinics. Survey questions included measures of the nurse work environment and levels of burnout, job dissatisfaction, and intent to leave.

DISCUSSION

Approximately one-third of primary care RNs were burnt out and dissatisfied with their jobs, with the highest risk of these outcomes among RNs in community clinics. Community clinic RNs were also significantly more likely to be Black or Hispanic/Latino, hold a Bachelor of Science in Nursing, and speak English as a second language (all p < .01). Across all settings, better nurse work environments were significantly associated with lower levels of burnout and job dissatisfaction (both p < .01).

CONCLUSION

Primary care practices must be equipped to support their RN workforce. Adequate nursing resources are especially needed in community clinics, as patients receiving primary care in these settings frequently face structural inequities.

Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study

BACKGROUND

Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity.

OBJECTIVE

To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes.

DESIGN

Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA.

PARTICIPANTS

Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017.

OUTCOME

Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017.

RESULTS

Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL.

CONCLUSIONS

A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.

Facilitation of team-based care to improve HTN management and outcomes: a protocol for a randomized stepped wedge trial

BACKGROUND

There are well-established guidelines for treating hypertension (HTN), yet only half of patients with HTN meet the defined target of < 140/90. Team-based care (TBC) is an evidence-based strategy for improving blood pressure (BP) management and control. TBC is defined as the provision of health services by at least two health professionals "who work collaboratively with patients and their caregivers to accomplish shared goals to achieve coordinated, high-quality care". However, primary care practices experience challenges to implementing TBC principles and care processes; these are more pronounced in small independent practice settings (SIPs). Practice facilitation (PF) is an implementation strategy that may overcome barriers to adopting evidence-based TBC to improve HTN management in SIPs.

METHODS

Using a stepped wedge randomized controlled trial design, we will test the effect of PF on the adoption of TBC to improve HTN management in small practices (< 5 FTE clinicians) in New York City, and the impact on BP control compared with usual care. We will enroll 90 SIPs and randomize them into one of three 12-month intervention waves. Practice facilitators will support SIPs to adopt TBC principles to improve implementation of five HTN management strategies (i.e., panel management, population health, measuring BP, supporting medication adherence, self-management). The primary outcome is the adoption of TBC for HTN management measured at baseline and 12 months. Secondary outcomes include the rate of BP control and sustainability of TBC and BP outcomes at 18 months. Aggregated data on BP measures are collected every 6 months in all clusters so that each cluster provides data points in both the control and intervention conditions. Using a mixed methods approach, we will also explore factors that influence the effectiveness of PF at the organization and team level.

DISCUSSION

This study will provide much-needed guidance on how to optimize adoption and sustainability of TBC in independent primary care settings to reduce the burden of disease related to suboptimal BP control and advance understanding of how facilitation works to improve implementation of evidence-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05413252 .

Connecting unattached patients to comprehensive primary care: a rapid review

INTRODUCTION

Lack of access to primary care providers (PCPs) is a significant hurdle to receiving high-quality comprehensive health care and creates greater reliance on emergency departments and walk-in clinics.

METHODS

We conducted a rapid review and analysis of the literature that discusses approaches to increasing access to continuous care for patients with no PCP ('unattached patients').

RESULTS

Five distinct themes across 38 resources were identified: financial incentives for patients and providers, health care organization, policy intervention, virtual care and health information technology (HIT), and medical education. Approaches that increased attachment were primary care models that combined two or more of these and reflected the Patient's Medical Home (PMH) model.

CONCLUSIONS

Although there are individual initiatives that could allow for temporary relief, long-term and community-wide success lies in designing models of primary care that use multiple tools, meet the needs of the community, and are supported by regional, provincial, and national policies.

The ambiguity of "we": Perceptions of teaming in dynamic environments and their implications

In healthcare, organizations increasingly call on clinicians and staff to team up fluidly to deliver integrated services across disciplines and settings. Yet little is known about how clinicians and staff perceive of team membership in healthcare environments where team boundaries are often ambiguous and continually shifting. We draw on the context of primary care in the United States, where fluid multi-disciplinary teamwork is commonly exhorted, to investigate the extent to which clinicians and staff perceive of various roles (e.g., physician, front desk) as members in their teams, and to identify potential implications. Using a survey fielded within 59 clinics (n = 828), we find substantial variation in individuals' perceptions of the roles they consider as team members during an episode of care (e.g., mean team size = 10.60 roles; standard deviation = 5.09). Perceiving more expansive sets of roles as team members exhibits a positive association with performance as measured by care quality (b = 0.02; p < .01) but a curvilinear association with job satisfaction. Separating an individual's perceived core (roles always perceived as part of the team) and periphery (roles sometimes perceived as part of the team), perceiving a larger core is positively associated with performance (b = 0.03 p < .01). In contrast, perceiving a larger periphery is marginally negatively associated with performance (b = -0.02, p < .10). This appears to be driven by divergence from the norm perception of the core, i.e., when individuals attribute to the periphery the roles that are considered by most others to be core. Our findings suggest that individuals viewing the roles they must team with more expansively may generate higher quality output but experience a personal toll. Delivering on the ideal of team-based care in dynamic environments may require helping team members gain clarity about their teammates and implementing policies that attend to job satisfaction as team boundaries shift and expand.

Nurse prescription start-up in a Spanish health organization: Nurses' preparedness and 6-month results

INTRODUCTION

Nurse prescribing is well consolidated in many countries. In Spain, recent legislation has allowed nurse to prescribe under specific conditions, but the implementation process is complex.

OBJECTIVES

First, to describe nurses' knowledge and expectations of nurse prescribing in a health institution in Spain. Second, to report the nurses' prescriptions in a pilot group at 6 months.

METHODS

A descriptive, online survey design was used to identify nurses' knowledge and expectations of prescribing. The results were compared according to the nurses' professional position and training. We analyzed the number and type of prescriptions issued in the first 6 months.

RESULTS

Training needs (overall score = 4.2/5) and lack of knowledge of the law (4.25/5) were scored lower by nurses with postgraduate training. Subjective assessment of preparedness among nurses was high (>4/5), and the highest-scoring expected impact was improvement in patients' experience (4.25/5). Years of nursing experience were negatively correlated with preparedness and the expectation of an increase in patient management errors. A total of 212 prescriptions were issued (2 drugs and 200 health devices).

CONCLUSIONS

Nurses perceived good preparedness but also the need for more training in medicines and prescribing law. Expectations of prescribing were favourable. Most prescriptions were for health devices.

Utilization of Medicare's chronic care management services by primary care providers

BACKGROUND

Medicare billing codes introduced in 2015 reimburses primary care providers for non-face-to-face, chronic care management (CCM) services rendered by clinical staff.

PURPOSE

The purpose of this manuscript was to describe provider trends in billed CCM services and identify factors associated with CCM utilization.

METHODS

Observational study using Medicare Public Use Files, 2015 to 2018. General, family, geriatric, and internal medicine physicians, nurse practitioners (NPs), and physician assistants (PAs) with billed primary care services were included. Multivariable analyses modeled associations between the CCM services and type of provider, adjusting for year, primary care services, practice, and patient characteristics.

FINDINGS

Among 140,465 physicians and 141,118 NPs/PAs, CCM services increased each year, yet remained underutilized: 2% to 7% of physicians and 0.3% to 1.3% of NPs/PAs billed CCM in 2018. Increases in beneficiaries (p < .0001), percentage of dually enrolled (p = .0134), and primary care services (p < .0001) predicted higher CCM utilization.

DISCUSSION

CCM utilization reflects practice-based efforts to improve patient access to care by enhancing care delivery.

Image-Based Artificial Intelligence in Wound Assessment: A Systematic Review

Significance: Accurately predicting wound healing trajectories is difficult for wound care clinicians due to the complex and dynamic processes involved in wound healing. Wound care teams capture images of wounds during clinical visits generating big datasets over time. Developing novel artificial intelligence (AI) systems can help clinicians diagnose, assess the effectiveness of therapy, and predict healing outcomes. Recent Advances: Rapid developments in computer processing have enabled the development of AI-based systems that can improve the diagnosis and effectiveness of therapy in various clinical specializations. In the past decade, we have witnessed AI revolutionizing all types of medical imaging like X-ray, ultrasound, computed tomography, magnetic resonance imaging, etc., but AI-based systems remain to be developed clinically and computationally for high-quality wound care that can result in better patient outcomes. Critical Issues: In the current standard of care, collecting wound images on every clinical visit, interpreting and archiving the data are cumbersome and time consuming. Commercial platforms are developed to capture images, perform wound measurements, and provide clinicians with a workflow for diagnosis, but AI-based systems are still in their infancy. This systematic review summarizes the breadth and depth of the most recent and relevant work in intelligent image-based data analysis and system developments for wound assessment. Future Directions: With increasing availabilities of massive data (wound images, wound-specific electronic health records, etc.) as well as powerful computing resources, AI-based digital platforms will play a significant role in delivering data-driven care to people suffering from debilitating chronic wounds.

Changes in Barriers That Cause Unmet Healthcare Needs in the Life Cycle of Adulthood and Their Policy Implications: A Need-Selection Model Analysis of the Korea Health Panel Survey Data

Using 68,930 observations selected from 16,535 adults in the Korea Health Panel Survey (2014-2018), this study explored healthcare barriers that prevent people from meeting their healthcare needs most severely during adulthood, and the characteristics that are highly associated with the barrier. This study derived two outcome variables: a dichotomous outcome variable on whether an individual has experienced healthcare needs, and a quadchotomous outcome variable on how an individual's healthcare needs ended. An analysis was conducted using a multivariable panel multinomial probit model with sample selection. The results showed that the main cause of unmet healthcare needs was not financial difficulties but non-financial barriers, which were time constraints up to a certain age and the lack of caring and support after that age. People with functional limitations were at a high risk of experiencing unmet healthcare needs due to a lack of caring and support. To reduce unmet healthcare needs in South Korea, the government should focus on lowering non-financial barriers to healthcare, including time constraints and lack of caring and support. It seems urgent to strengthen the foundation of "primary care", which is exceptionally scarce now, and to expand it to "community-based integrated care" and "people-centered care".

Designing a pharmacist primary care certificate training program based on employer perceptions

Background

As the pharmacy profession transforms toward practice centered around direct patient care and clinical services, upskilling the existing workforce may be required for pharmacists to take on expanded roles, especially in an increasingly competitive job market.

Objective

To explore pharmacist employer perceptions of a primary care certificate training program including its design, value, and relevance and to develop and implement a pharmacist primary care certificate training program based on study results.

Methods

Focus groups were conducted to a point of saturation in December 2020 via video conference. Participants were identified via the study institution's continuing professional development registrant listserv and invited to participate via self-selection. Interviews were recorded, transcribed, and underwent inductive thematic analysis.

Results

Four focus groups were conducted with 15 pharmacist employers. Employers perceived primary care certificate training as valuable, helping pharmacists sustain shifting roles and increasing opportunities in a competitive job market. A combination of clinical and practice management topics with emphasis on an experiential component was recommended to achieve expected competency levels and favorably influence hiring decisions. The primary care certificate was specifically recommended to pharmacists aiming to transition into primary care or for pharmacists who did not complete residency training.

Conclusions

This study's findings informed development of a pharmacist primary care certificate program containing didactic and experiential training on a variety of key topics. As pharmacists' roles evolve, this program may prepare pharmacists to engage in direct patient care and develop skills and expertise necessary to succeed in outpatient primary care.

Optimizing Occupations, Habits, and Routines for Health and Well-Being With Lifestyle Redesign®: A Synthesis and Scoping Review

IMPORTANCE

Lifestyle Redesign® originated as a preventive occupational therapy intervention for healthy older adults, and it was found to be both effective and cost effective in the Well Elderly Studies initiated in the 1990s. Building on that empirical foundation, the scope of Lifestyle Redesign has been greatly expanded as a general intervention framework addressing prevention and chronic condition management in a wide range of populations, settings, and conditions. Yet until now, its full scope, defining characteristics, and supporting evidence have not been clearly and succinctly described, limiting its potential reach and impact.

OBJECTIVE

To outline the definition and key characteristics of Lifestyle Redesign, provide a scoping review of its evidence base and future directions for research, describe its current applications, and make recommendations for its use in clinical practice.

EVIDENCE REVIEW

We searched PubMed and CINAHL, tables of contents of 10 occupational therapy journals, and citations in two seminal Lifestyle Redesign publications to identify articles published in 1997-2020 that described quantitative outcomes (for n ≥ 20) of interventions meeting the defining characteristics of Lifestyle Redesign.

FINDINGS

Our scoping review yielded 12 publications providing supportive evidence for Lifestyle Redesign's positive impact on a range of health and well-being outcomes among both well populations and those with chronic conditions.

CONCLUSIONS AND RELEVANCE

Lifestyle Redesign has the potential to meet a growing need in clinical and community settings for health care services that address prevention, health promotion, and chronic disease management. What This Article Adds: Current evidence supports the use of Lifestyle Redesign to improve health and well-being for a range of client populations. This review outlines its defining characteristics and current applications to improve its implementation in clinical practice and expand related research efforts.

The role of clinician assistants in addressing perinatal depression

BACKGROUND

Upwards of one in seven individuals experience perinatal depression and many individuals cannot access treatment. In response, perinatal depression is increasingly being managed in the obstetric setting. This study aimed to characterize the experiences of clinicians and clinician assistants to inform the extent to which clinician assistants can help address depression in obstetric settings.

METHODS

This cross-sectional analysis used data from an ongoing cluster randomized control trial: The PRogram In Support of Moms (PRISM). Participants included clinicians (physicians, certified nurse midwives, nurse practitioners) and clinician assistants (medical assistants, nursing assistants). Baseline data regarding practices and attitudes of clinicians and clinician assistants toward addressing depression in the obstetric setting were described. Logistic regressions were used to examine the association of clinician time to complete work and depression management.

RESULTS

Clinician assistants experienced significantly fewer time constraints than did clinicians. However, having adequate time to complete work was not significantly associated with increased depression management in clinicians. Clinician assistants reported feeling that addressing depression is an important part of their job, despite variation in doing so.

CONCLUSION

Clinician assistants are interacting with perinatal women extensively and are a vital part of obstetric care workflows. Clinician assistants report that they want to address depression and have time to do so. Thus, clinician assistants may be poised to help address the mental health needs of perinatal individuals.

Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention

PURPOSE

The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention.

METHOD

This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings.

RESULTS

The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge.

CONCLUSIONS

Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.

Meeting the need for nurse practitioner clinicals: A survey of practitioners

BACKGROUND

The increase in the number of nurse practitioner (NP) students requires increased clinical practice sites and prepared preceptors.

PURPOSE

This study describes NPs' clinical experiences as a student and their current practices as an NP preceptor.

METHODOLOGY

A descriptive study design used a 38-item web-based survey conducted in June and July 2021.

RESULTS

A total of 334 NPs practicing in Texas responded; most had been NPs for 10 or fewer years (58.2%) and in their positions less than 5 years (50.3%). A plurality of respondents was required to find their own clinical placements (46%). The most common challenge in obtaining clinical placements was finding preceptors (33%). Nurse practitioners reported excellent clinical experiences (39.3%) as a student and believed that they were generally well prepared for the NP role (38.9%) and to care for their specialty patient population (46.1%) upon graduation. Sixty percent of respondents reported not currently precepting, 37.6% had never been asked to precept, whereas 32.8% reported that employers restricted precepting. Family NPs were the least likely to precept.

CONCLUSIONS

Nurse practitioners report positive clinical experiences that prepare them for NP careers. Multiple opportunities exist to enlist additional NPs as preceptors for NP students.

IMPLICATIONS

There is capacity within the current NP workforce to meet the clinical educational needs of NP students. Future work should examine best practices to engage NPs who are not currently preceptors. As policies change NP education, research should examine the implications of the preparation for NP roles at the time of graduation, organizational outcomes, and quality of care.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015-2019

BACKGROUND

Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England.

METHODS

We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors.

RESULTS

Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups.

CONCLUSIONS

Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Development and Implementation of a Combined Nurse Care Manager and Community Health Worker Training Curriculum to Address Hypertension Disparities

The use of nurse care managers (CMs) and community health workers (CHWs) has demonstrated effectiveness in supporting improved blood pressure management among racially, ethnically, and socioeconomically minoritized populations. We partnered with a community advisory board (CAB) to develop a CM and CHW training curriculum and team-based collaborative care intervention to address uncontrolled hypertension. The objective of this study was to train CMs and CHWs to implement patient-centered techniques and address social determinants of health related to hypertension control. In partnership with a CAB, we developed and implemented a training curriculum for the CM/CHW collaborative care team. The training improved CM and CHW confidence in their ability to address medical and nonmedical issues that contribute to uncontrolled hypertension in their patients; however, preexisting norms and beliefs among CMs and CHWs created challenges with teamwork. The training curriculum was feasible and well-received. Additionally, the CMs' and CHWs' reactions provided insights to improve future collaborative care training and teamwork.

Association of Medicaid Expansion With Emergency Department Visits by Medical Urgency

IMPORTANCE

Relatively little is known about the association of the Medicaid eligibility expansion under the Patient Protection and Affordable Care Act with emergency department (ED) visits categorized by medical urgency.

OBJECTIVE

To estimate the association between state Medicaid expansions and ED visits by the urgency of presenting conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the Healthcare Cost and Utilization Project State Emergency Department Databases from January 2011 to December 2017 for 2 states that expanded Medicaid in 2014 (New York and Massachusetts) and 2 states that did not (Florida and Georgia). Difference-in-differences regression models were used to estimate the changes in ED visits overall and further stratified by the urgency of the conditions using an updated version of the New York University ED algorithm between the states that expanded Medicaid and those that did not, before and after the expansion. Data were analyzed between June 7 and December 12, 2021.

EXPOSURE

State-level Medicaid eligibility expansion.

MAIN OUTCOMES AND MEASURES

Emergency department visits per 1000 population overall and stratified by medical urgency of the conditions.

RESULTS

In total, 80.6 million ED visits by 26.0 million individuals were analyzed. Emergency department visits were concentrated among women (59.3%), non-Hispanic Black individuals (28.3%), non-Hispanic White individuals (47.8%), and those aged 18 to 34 years (47.5%) and 35 to 44 years (20.4%). The rates of ED visits increased by a mean of 2.4 visits in nonexpansion states and decreased by a mean of 2.2 visits in expansion states after 2014, resulting in a significant regression-adjusted decrease of 4.7 visits per 1000 population (95% CI, -7.7 to -1.5; P = .003) in expansion states. Most of this decrease was associated with decreases in ED visits by conditions classified as not emergent (-1.5 visits; 95% CI, -2.4 to -0.7; P < .001), primary care treatable (-1.1 visits; 95% CI, -1.6 to -0.5; P < .001), and potentially preventable (-0.3 visits; 95% CI, -0.5 to -0.1; P = .02). No significant changes were observed for ED visits related to injuries and conditions classified as not preventable (-1.4; 95% CI, -3.1 to 0.3; P = .10), as well as for substance use and mental health disorders (0.0; 95% CI, -0.2 to 0.2; P = .94).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that Medicaid expansion was associated with decreases in ED visits, for which decreases in ED visits for less medically emergent ED conditions may have been a factor.

Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans

Background

Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA.

Purpose

The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers.

Methods

We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]).

Results

Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99).

Conclusion

In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.

Characteristics Associated With Financial or Non-financial Barriers to Healthcare in a Universal Health Insurance System: A Longitudinal Analysis of Korea Health Panel Survey Data

While many studies have explored the financial barriers to healthcare, there is little evidence regarding the non-financial barriers to healthcare. This study identified characteristics associated with financial and non-financial barriers to healthcare and quantified the effects of these characteristics in South Korea, using a nationally representative longitudinal survey dataset. Overall, 68,930 observations of 16,535 individuals aged 19 years and above were sampled from Korea Health Panel survey data (2014-2018). From self-reported information about respondents' experiences of unmet healthcare needs, a trichotomous dependent variable-no barrier, non-financial barrier, and financial barrier-was derived. Sociodemographics, physical and health conditions were included as explanatory variables. The average adjusted probability (AAP) of experiencing each barrier was predicted using multivariable and panel multinomial logistic regression analyses. According to the results, the percentage of people experiencing non-financial barriers was much higher than that of people experiencing financial barriers in 2018 (9.6 vs. 2.5%). Women showed higher AAPs of experiencing both non-financial (9.9 vs. 8.3%) and financial barriers (3.6 vs. 2.5%) than men. Men living in the Seoul metropolitan area showed higher AAPs of experiencing non-financial (8.7 vs. 8.0%) and financial barriers (3.4 vs. 2.1%) than those living outside it. Household income showed no significant associations in the AAP of experiencing a non-financial barrier. People with a functional limitation exhibited a higher AAP of experiencing a non-financial barrier, for both men (17.8 vs. 7.8%) and women (17.4 vs. 9.0%), than those without it. In conclusion, people in South Korea, like those in most European countries, fail to meet their healthcare needs more often due to non-financial barriers than financial barriers. In addition, the characteristics associated with non-financial barriers to healthcare differed from those associated with financial barriers. This finding suggests that although financial barriers may be minimised through various policies, a considerable degree of unmet healthcare needs and disparity among individuals is very likely to persist due to non-financial barriers. Therefore, current universal health insurance systems need targeted policy instruments to minimise non-financial barriers to healthcare to ensure effective universal health coverage.

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

The effect of a single visit to a health coach on perceived health in 50-year old residents in a high-income country - a randomised controlled trial

OBJECTIVE

To evaluate the one-year-effect of a single visit to a health coach on perceived health and exercise level in 50-year-old citizens.

DESIGN

One factor design randomised controlled trial.

SETTING

Participants were randomly selected from the Swedish Population Register.

SUBJECTS

50-year-old residents of the town of Alingsås, Sweden (n = 105).

INTERVENTION

The intervention group (n = 52) received a single one-hour visit to a health coach. The control group (n = 53) received no intervention.

MAIN OUTCOME MEASURES

Change over 12 months in the SF-36 dimensions physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, mental health, physical component summary and mental component summary. Reported health transition at follow-up. Change in exercise level.

RESULTS

The control group changed their perceived health more favourable than the intervention group in the following dimensions of the SF-36; general health (p = 0.0055-0.025), role-emotional (p = 0.034-0.040) and mental component summary (p = 0.033-0.073).

CONCLUSION

A single visit to a health coach does not improve perceived health or exercise-level in 50-year-old citizens. On the contrary it may make perceived health worse.Key pointsResearch on health coaching has emerged in the last 20 years, but is diverse and the characteristics of a successful health coaching intervention are still unknown.There is a lack of randomised controlled trials evaluating long-term effectiveness of health coaching.This randomised controlled trial concludes that a single visit to a health coach does not improve, but rather impairs, perceived health in 50-year olds.

The effect of nurse practitioner scope of practice laws on primary care delivery

Nurse practitioners (NPs) are an increasingly integral part of the primary care workforce. NPs' authority to practice without physician oversight is regulated by state-level scope of practice (SOP) restrictions. To the extent that SOP restrictions prevent NPs from practicing to their full abilities and capacity, they could create inefficiencies and restrict access to health care. In this paper, I study what happens at primary care practices when states relax their SOP laws. Using a novel dataset of claims and electronic health records paired with a difference-in-differences research design, I quantify the effects of relaxing SOP laws on: (1) NPs' autonomy in their day-to-day jobs; (2) total workload and patient allocation between NPs and physicians; and (3) the provision of low-value services at primary care practices. I find some evidence that NPs practice more autonomously following SOP changes, but I find no evidence that relaxing SOP laws changes the volume nor allocation of patients to NPs, nor the provision of low-value services. Given the lower reimbursement that NPs typically receive, these findings suggest that allowing NPs to practice without physician oversight could reduce health care spending, without harming patients.

Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians

OBJECTIVE

Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system.

DESIGN

Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition.

PARTICIPANTS

VHA employees that self-identify as PCPs.

MAIN MEASURES

Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction).

RESULTS

We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%).

CONCLUSION

Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.

Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research

In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.

Integration of Primary Care Teams Within the Examination Room: A Qualitative Study of Advanced Team-Based Care

Multidisciplinary teams deliver high-quality care in complex primary care environments. Using qualitative interviews, we explored the interpersonal dynamics of care team members from 2 models-traditional team-based care and "advanced team-based care" (aTBC). Two differentiating themes emerged-the ways care teams learned and collaborated. aTBC participants described learning from each other and integrating their roles and tasks more so than the traditional model. These differences have implications for patient care and care team member well-being. Our results provide a framework for improving team-based care models and for further research on the impact of adaptive learning and integration in primary care settings.

Priorities for family physician and general practitioner recruitment and retention in Singapore: a PRIORITIZE study

Background

A shortage of primary care physicians has been reported in many countries. Primary care systems are diverse and the challenges leading to a decline in workforce are at times context-specific and require tailored solutions. Inviting frontline clinicians to share their insights can help identify optimal strategies for a particular setting. To determine priorities for family physicians’ and general practitioners’ recruitment and retention in Singapore, we invited primary care physicians to rank pertinent strategies using PRIORITIZE, a transparent, systematic priority-setting approach.

Methods

The study advisory board, consisting of representatives of Singapore’s key primary care stakeholders, determined the criteria for prioritising of general practitioners (GPs) and family physicians (FPs) recruitment and retention strategies in Singapore. A comprehensive list of GPs and FPs recruitment and retention strategies was extracted from a recent systematic review of the relevant literature. A questionnaire listing the strategies and the scoring criteria was administered online to doctors practicing in public and private sector in Singapore. Respondents’ scores were combined to create a ranked list of locally most relevant strategies for improving GPs and FPs recruitment and retention.

Results

We recruited a diverse sample of 50 GPs and FPs practicing in a variety of primary care settings, many with a range of additional professional responsibilities. Around 60 and 66% of respondents thought that there was a problem with recruitment and retention of GPs and FPs in Singapore, respectively. Strategies focusing on promoting primary care by emphasizing the advantages and enhancing the status of the profession as well as training-related strategies, such as sub-specialisation and high-quality rotations were considered priorities for improving recruitment. For retention of GPs and FPs, improving working conditions by increasing GPs’ and FPs’ salary and recognition, as well as varying or reducing time commitment, were seen as the most important strategies. The ranking between physicians working in public and private sector was mostly similar, with nine out of the top ten recruitment and retention strategies being the same.

Conclusion

Primary care physicians’ ranking of recruitment and retention strategies for GPs and FPs in Singapore provide important insight into the challenges and the solutions as seen by the members of the profession themselves. This information can guide future policy and decision making in this area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01570-1.

Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings

PURPOSE

Clinicians and policy makers are exploring the role of primary care in improving patients' social conditions, yet little research examines strategies used in clinical settings to assist patients with social needs.

METHODS

Study used semistructured interviews with leaders and frontline staff at 29 diverse health care organizations with active programs used to address patients' social needs. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity, and use of referrals to community-based organizations (CBOs).

RESULTS

Organizations used case management programs to assist patients with social needs through referrals to CBOs and regular follow-up with patients. About one-half incorporated care for social needs into established case management programs and the remaining described standalone programs developed specifically to address social needs independent of clinical needs. Referrals were the foundation for assistance and included preprinted resource lists, patient-tailored lists, and warm handoffs to the CBOs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance completing patients' applications for services or conducting home visits. Organizations described 4 operational challenges in addressing patients' social needs: (1) effectively engaging CBOs; (2) obtaining buy-in from clinical staff; (3) considering patients' perspectives; and (4) ensuring program sustainability.

CONCLUSION

As the US health care sector faces pressure to improve quality while managing costs, many health care organizations will likely develop or rely on case management approaches to address patients' social conditions. Health care organizations may require support to address the key operational challenges.Visual abstract.

Career Ladders for Medical Assistants in Primary Care Clinics

BACKGROUND

This study examines the use of career ladders for medical assistants (MAs) in primary care practices as a mechanism for increasing wages and career opportunity for MAs. A growing body of research on primary care suggests that successful expansion of support staff roles such as MAs may have positive organizational and quality of care outcomes, but little is known about worker outcomes.

OBJECTIVE

Evaluate the effectiveness of career ladders in improving wages and career opportunity among MAs.

DESIGN

We use a mixed-methods design to evaluate the impact of career ladders on MA job quality.

PARTICIPANTS

We draw on interview data collected from 115 key informants at four large health systems (ranging from 24 to 29 clinics each), and we analyze wage and employment data for MAs from primary care clinics in the four health systems in the sample.

APPROACH

We describe the MA career ladder context and infrastructure within primary care clinics and evaluate the rewards to MAs for participation in the career ladder programs.

KEY RESULTS

The expanded roles within career ladders for MAs focused on the following four clinical and educational areas: panel management and care coordination, EHR documentation support, supporting delivery of person-centered care, and supervision and training. The three primary components of the career ladder infrastructure were training and education for MAs and providers, credentialing and certification for MAs, and differentiated job levels for MAs. The use of career ladders in the four large health systems in our case study sample resulted in yearly income increases ranging from $3000 to $10,000 annually.

CONCLUSION

Investing in career ladders in primary care clinics can improve MA job quality while also potentially addressing issues of equity, efficiency, and quality in the health care sector.

Identifying key roles of the pharmacy technician in primary care settings

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

As the pharmacist's role expands, particularly in primary care practice settings, there is an opportunity for expansion of pharmacy technician duties to aid in administrative and clinical tasks that do not require the pharmacist's professional judgment. Identifying, defining, and expanding the roles of pharmacy technicians has been deemed a key part of the pharmacy practice model. These roles have been shown to enhance pharmacist efficiency and patient outreach; however, examples of the various innovative activities performed by technicians in the primary care setting are lacking in the literature.

METHODS

The duties of primary care pharmacist technicians were compiled and defined in 2 different healthcare systems. The role of the technician was separately implemented at each institution, and study designs and protocols were individually created and executed. One institution utilized a 4-round consensus-building process to systematically refine and codify tasks for a dictionary of duties. The second institution utilized a free-text survey, task documentation data in the electronic medical record, and a telephone discussion with the technicians.

RESULTS

Despite a lack of methods- and data-sharing between the 2 institutions, similar tasks were identified, including conducting patient outreach, assisting with medication affordability and access, providing patient education, managing referrals, and scheduling appointments. Differences in technician involvement were noted in areas such as prior authorization, care coordination meetings, and quality improvement projects.

CONCLUSION

Pharmacy technicians are a helpful, yet underutilized, resource in the primary care setting. Further exploration of technician roles is needed to determine the financial and clinical impact of expanding these roles.

Primary care workforce paradox: A physician shortage and a PA and NP surplus

OBJECTIVE

Primary care workforce projections continue to predict significant physician shortages. An oversupply of primary care physician assistants (PAs) and NPs also is predicted. This paradox calls into question the assumptions that underlie workforce projection models, which likely underestimate the primary care contributions of PAs and NPs.

METHODS

Federally qualified health center data from the 2016-2019 Uniform Data System were used to calculate the number of clinic visits per full-time equivalent (FTE) physician, PA, and NP. Visits per FTE were compared across provider type to determine provider-specific productivity ratios.

RESULTS

The combined PA and NP productivity ratio increased relative to physicians in each year, ranging from 0.85 in 2016 to 0.88 in 2019. Clinic visits per FTE for PAs and family physicians were nearly equivalent.

CONCLUSIONS

Primary care workforce projection models should be reexamined to more accurately capture the productivity of PAs and NPs.

Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

To translate improvements in diabetes management into improved outcomes, it is essential to improve care delivery. To help guide clinicians and health organizations in their efforts to achieve these improvements, this article briefly describes key components underpinning effective diabetes care and six categories of innovations in approaches to improve diabetes care delivery: (1) team-based clinical care; (2) cross-specialty collaboration/integration; (3) virtual clinical care/telehealth; (4) use of community health workers (CHWs) and trained peers to provide pro-active self-management support; (5) incorporating screening for and addressing social determinants of health into clinical practice; and (6) cross-sectoral clinic/community partnerships.

Building the evidence-base to reduce electronic health record-related clinician burden

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.