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Kim DK, Scott P, Poghosyan L, Martsolf GR. Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels. Nurs Outlook 2024; 72:102190. [PMID: 38788271 DOI: 10.1016/j.outlook.2024.102190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/23/2024] [Accepted: 04/27/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored. PURPOSE To estimate the impact of NP panel management on workforce outcomes. METHODS Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management. DISCUSSION Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours. CONCLUSION Interventions to reduce work hours could help NPs deliver quality care without burnout.
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Affiliation(s)
- Do Kyung Kim
- School of Nursing, University of Pittsburgh, Pittsburgh, PA.
| | - Paul Scott
- School of Nursing, University of Pittsburgh, Pittsburgh, PA
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2
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Gigli KH, Calhoun J, Dierkes AM, Martsolf GR. The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring. Policy Polit Nurs Pract 2024; 25:20-28. [PMID: 37880970 DOI: 10.1177/15271544231204879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
Demand for acute care is forecasted to grow in the United States. To meet this demand, nurse practitioners (NPs) are increasingly employed in acute care settings. Yet, there is concern about an adequate supply of acute care NPs given demand. Further, professional nursing organizations recommend aligning an NP's role with their education, certification, licensure, and practice. Given workforce constraints and the policy environment, little is known about how hospitals approach hiring NPs for acute care roles. The purpose of this study was to explore advanced practice provider (APP) directors' approaches to hiring NPs within the context of alignment and describe factors that influence hiring decisions. We conducted semi-structured interviews with 17 APP directors in hospitals and health systems. Interviews were recorded, transcribed, and coded using an iterative, hybrid inductive and deductive method. Two themes emerged: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments. Practices around hiring NPs varied across institutions influenced by organization and state policies and regulations, workforce availability, and institutional culture. Most APP directors recognized trends towards hiring aligned NPs for acute care roles. However, they also identified barriers to fully aligning their NP workforce and described adaptive strategies including hiring physician assistants, building relationships with APP schools, and leveraging hospital resources to develop the APP workforce to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications of alignment for patient and organizational outcomes.
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Affiliation(s)
| | - Jackie Calhoun
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Andrew M Dierkes
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Grant R Martsolf
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
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3
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Martsolf GR, Porat-Dahlerbruch J, Poghosyan L. Response to Drs. McCurren and Trautman. Nurs Outlook 2024; 72:102101. [PMID: 38065825 DOI: 10.1016/j.outlook.2023.102101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/10/2023] [Accepted: 11/20/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Grant R Martsolf
- Acute and Tertiary Care Department, University of Pittsburgh School of Nursing, Pittsburgh, PA
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4
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Poghosyan L, Liu J, Spatz E, Flandrick K, Osakwe Z, Martsolf GR. Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease. J Gen Intern Med 2024; 39:61-68. [PMID: 37620724 PMCID: PMC10817858 DOI: 10.1007/s11606-023-08367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients. OBJECTIVE To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease. DESIGN In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease. PARTICIPANTS A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included. MAIN MEASURES All-cause and ambulatory care sensitive condition hospitalizations in 2018. KEY RESULTS There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries. CONCLUSIONS Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.
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Affiliation(s)
- Lusine Poghosyan
- School of Nursing, Columbia University, 560 West 168th Street, Office 624, New York, NY, 10032, USA.
- Mailman School of Public Health, Columbia University, New York, USA.
| | - Jianfang Liu
- School of Nursing, Columbia University, 560 West 168th Street, Office 624, New York, NY, 10032, USA
| | - Erica Spatz
- School of Medicine, Yale University, New Haven, CT, USA
| | - Kathleen Flandrick
- School of Nursing, Columbia University, 560 West 168th Street, Office 624, New York, NY, 10032, USA
| | - Zainab Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Grant R Martsolf
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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5
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Martsolf GR, Gigli K, Case B, Dill J, Dierkes A. Describing the male registered nursing workforce toward increasing male representation in professional nursing. Nurs Outlook 2023; 71:102081. [PMID: 37944199 DOI: 10.1016/j.outlook.2023.102081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Men are significantly underrepresented in nursing and increasing their numbers should be a priority. PURPOSE To describe the male nursing workforce in terms of size, demographics, education, and work settings. METHODS Using data from the 2018 National Sample Survey of Registered Nurses, we performed a secondary descriptive analysis. FINDINGS We find that 9.6% of registered nurses are men. Men are more likely than women to hold an associate degree and clinical doctorates, be nurse anesthetists and supervisors, and work in emergency settings but less likely than females to participate in teaching. DISCUSSION To increase male representation in nursing we must simultaneously rearticulate what it means for a job to be "female" while also showing that nursing incorporates many skills and interests traditionally coded as "male." We can also show men that nursing offers appealing employment that can lead to a deeply fulfilling personal and professional life.
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Affiliation(s)
| | - Kristin Gigli
- College of Nursing and Health Innovation, University of Texas Arlington, Arlington, TX
| | - Brendan Case
- Human Flourishing Program, Harvard University, Cambridge, MA
| | - Janette Dill
- School of Public Health, University of Minnesota, Minneapolis, MN
| | - Andrew Dierkes
- School of Nursing, University of Pittsburgh, Pittsburgh, PA
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Sim ES, Belsky MA, Konanur A, Yan A, Shaffer AD, Williams K, Martsolf GR, Chi DH, Jabbour N. Adherence to Tympanostomy Tube Clinical Practice Guidelines in an Advanced Practice Provider Clinic. Ann Otol Rhinol Laryngol 2023; 132:1110-1116. [PMID: 36412134 DOI: 10.1177/00034894221135282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE We compared adherence rates by attending otolaryngologists (OTOs) and advanced practice providers (APPs) to the 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) for children with recurrent acute otitis media (RAOM) undergoing bilateral myringotomy and tympanostomy tube placement (BMT). METHODS Patients aged 6 months to 12 years old undergoing BMT for RAOM who had a pre-operative visit with an independent APP or OTO were reviewed. Patients satisfied CPG criteria if middle ear effusion was identified at the pre-operative visit (pre-op) or if they did not have effusion but met exception criteria based on their risk for developmental difficulties and contraindications to medical therapy. Adherence rates between APPs and OTOs were compared. Agreement between pre-op and time-of-surgery middle ear effusion identification was assessed. RESULTS Nine hundred twenty-three patients were included. Six hundred one patients were seen by OTOs and 322 by APPs. Middle ear effusion was identified at pre-op in 84% of APP patients and in 76% of OTO patients (P = .005). Eight percent of APP patients and 11% of OTO patients met exception criteria (P = .138). Overall, 87% of OTO patients and 92% of APP patients met either CPG or exception criteria for BMT (P = .037). A logistic regression model demonstrated that pre-op provider type did not significantly impact rates of agreement between pre-op visit and time-of-surgery middle ear effusion identification. CONCLUSIONS Independent APP-led clinics can reliably and effectively deliver evidence-based care for prevalent conditions such as RAOM at similar rates of adherence to CPGs as OTOs.
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Affiliation(s)
- Edward S Sim
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael A Belsky
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anisha Konanur
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Annie Yan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | - David H Chi
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Noel Jabbour
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Liu J, Ghaffari A, Martsolf GR, Poghosyan L. The Multilevel Reliability and Interrater Agreement of the Nurse Practitioner Primary Care Organizational Climate Questionnaire. J Nurs Meas 2023; 31:448-457. [PMID: 37558251 DOI: 10.1891/jnm-2021-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Background and Purpose: It is critical to accurately measure and understand the nurse practitioner (NP) work environment in which individual NP information is gathered but decisions or inferences are made at an aggregated, group level. However, there is little research on preconditions of aggregating individual-level data into group level in nursing research. This study was conducted to assess the multilevel reliability and group interrater agreement (IRA) of the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Methods: Secondary data analysis from a cross-sectional survey with 247 NPs in 112 practices across 6 U.S. states in 2018-2019 was used. Results: The generalizability coefficients and values of IRA were acceptable (> .70), and values of ICC(1) were significant (.18-.38). Conclusions: Aggregating individual NP data to a higher group-level work environment construct is acceptable.
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Affiliation(s)
- Jianfang Liu
- Columbia University Irving Medical Center, New York, NY, USA
| | - Affan Ghaffari
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Grant R Martsolf
- University of Pittsburgh School of Nursing, Pittsburgh, PA, United States
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8
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Poghosyan L, Courtwright S, Flandrick KR, Pollifrone MM, Schlak A, O'Reilly-Jacob M, Brooks Carthon JM, Gigli KH, Porat-Dahlerbruch J, Alexander G, Brom H, Maier CB, Timmons E, Ferrara S, Martsolf GR. Advancement of research on nurse practitioners: Setting a research agenda. Nurs Outlook 2023; 71:102029. [PMID: 37619489 PMCID: PMC10810357 DOI: 10.1016/j.outlook.2023.102029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION The agenda can advance evidence on the NP workforce to guide policy and practice.
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Affiliation(s)
| | | | | | | | - Amelia Schlak
- Office of Research and Development, Department of Veteran Affairs, Washington DC, WA
| | | | | | - Kristin Hittle Gigli
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Heather Brom
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
| | - Claudia B Maier
- Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany
| | - Edward Timmons
- John Chambers College of Business and Economics, West Virginia University, Morgantown, WV
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Martsolf GR, Kandrack R, Ferrara SA, Poghosyan L. The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care. Inquiry 2023; 60:469580231171333. [PMID: 37139742 PMCID: PMC10161305 DOI: 10.1177/00469580231171333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.
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10
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Poghosyan L, Liu J, Schlak A, Courtwright S, Flandrick K, Nantsupawat A, Martsolf GR. Primary Care Nurse Practitioner Burnout and ED Use and Hospitalizations Among Chronically Ill Medicare Beneficiaries. Inquiry 2023; 60:469580231219108. [PMID: 38146179 PMCID: PMC10752115 DOI: 10.1177/00469580231219108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 12/27/2023]
Abstract
Nurse practitioners (NPs) represent the fastest-growing workforce of primary care clinicians in the United States. Their numbers are projected to grow in the near future. The NP workforce can help the country meet the rising demand for care services due to the aging population and increasing chronic disease burden. Yet, increased burnout among these clinicians may affect their ability to deliver high-quality, safe care. We investigated how NP burnout in primary care practices affects patient outcomes, including emergency department (ED) use and hospitalizations, among older adults with chronic conditions. In 2018-2019, we collected survey data from 1244 primary care NPs from 6 geographically diverse states on their burnout and merged the survey data with data from Medicare claims on ED use and hospitalizations among 467 466 older adults with chronic conditions. 26.3% of NPs reported burnout. Using logistic regression models, we found that with a 1-unit increase in the standardized burnout score, the odds of an ED visit increased by 2.8% (OR = 1.028; P-value = .035); Ambulatory Care Sensitive Conditions (ACSC) ED visit by 3.2% (OR = 1.032; P-value = .019); hospitalization by 3.9% (OR = 1.039; P-value = .001); and ACSC hospitalization by 6.2% (OR = 1.062; P-value = .001). Our findings indicate that if chronically ill older adults receive care in primary care practices with higher NP burnout rates they are more likely to use EDs and hospitals. Policy and practice efforts, such as improving NP working conditions, should be undertaken to reduce NP burnout in primary care practices to potentially prevent acute care use.
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Affiliation(s)
| | | | - Amelia Schlak
- Department of Veteran’s Affairs, Office of Research and Development, Washington, DC, USA
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Harrison JM, Kranz AM, Chen AYA, Liu HH, Martsolf GR, Cohen CC, Dworsky M. The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity. Inquiry 2023; 60:469580231167013. [PMID: 37102473 PMCID: PMC10150436 DOI: 10.1177/00469580231167013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/28/2023]
Abstract
Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.
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Affiliation(s)
| | | | | | | | - Grant R. Martsolf
- RAND Corporation, Pittsburgh, PA,
USA
- University of Pittsburgh School of
Nursing, Pittsburgh, PA, USA
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Abstract
With the growth of vertical integration among physician practices (i.e., hospital-physician integration), there have been many studies of its effects on health care treatments and spending. It is unknown if integration shapes provider configurations, especially against the backdrop of increasing employment of nurse practitioners (NPs) and physician assistants (PAs) across specialties. Using a longitudinal panel of 144,289 practices (2008-2015), we examined the association of vertical integration with NP and PA employment. We find positive associations between vertical integration and newly employing NPs and PAs within physician practices; however, the relationships differ by practice specialty type as well as timing of vertical integration. Supplementary analyses offer supporting evidence for coinciding enhancements to practice productivity, diversification, and provider task allocation. Our results suggest that vertical integration may promote interdisciplinary provider configurations, which has the potential to improve care delivery efficiency.
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13
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Poghosyan L, Pulcini J, Chan GK, Dunphy L, Martsolf GR, Greco K, Todd BA, Brown SC, Fitzgerald M, McMenamin AL, Solari-Twadell PA. State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners. Nurs Outlook 2022; 70:28-35. [PMID: 34763899 PMCID: PMC8346350 DOI: 10.1016/j.outlook.2021.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/21/2021] [Accepted: 07/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions. PURPOSE To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research. METHODS We have conducted a thorough review of the existing literature. FINDINGS NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost. DISCUSSION The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.
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Affiliation(s)
| | - Joyce Pulcini
- George Washington University School of Nursing, Ashburn, VA
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14
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Barnes H, Richards MR, Martsolf GR, Nikpay SS, McHugh MD. Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis. Health Care Manage Rev 2022; 47:21-27. [PMID: 33181552 PMCID: PMC8110602 DOI: 10.1097/hmr.0000000000000291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. PURPOSE The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. METHODS Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. RESULTS Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. CONCLUSION NP and PA employment was positively associated with increases in Medicaid participation. PRACTICE IMPLICATIONS As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.
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Affiliation(s)
- Hilary Barnes
- Assistant Professor, University of Delaware School of Nursing, Newark
| | - Michael R. Richards
- Associate Professor, Department of Economics, Hankamer School of Business, Baylor University, Waco, Texas
| | - Grant R. Martsolf
- Professor, Department of Acute and Tertiary Care, University of Pittsburgh School Nursing, and Adjunct Policy Researcher, RAND Corporation, Pittsburgh, Pennsylvania
| | - Sayeh S. Nikpay
- Assistant Professor, Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Matthew D. McHugh
- Independence Chair for Nursing Education, Professor of Nursing, Associate Director, Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Martsolf GR, Kim DK, Germack HD, Harrison JM, Poghosyan L. Determinants of nurse practitioner independent panel management in primary care. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND The Caregiver Advise, Record, Enable (CARE) Act encourages inclusion of family caregivers in the hospitalization process for patients. Translating the state laws into meaningful changes within the health care delivery system can be challenging and requires time. This study sought to examine early compliance with and implementation of the CARE Act reported by hospitals in the Commonwealth of Pennsylvania. METHODS We sent an online survey to hospital executives in Pennsylvania in 2017. Descriptive statistics were computed to examine hospital characteristics and used to assess compliance and implementation of the CARE Act tenets. RESULTS Most hospitals reported that changes have been and are being made to comply with the CARE Act (90.9%). Hospital executives reported that the family caregiver designation is available in 63.6% of the hospitals and notification of patient discharge is available in 45.5%. Hospital executives reported that family caregiver education and instruction is occurring in 31.8% of all inpatient stays. Hospital executives indicated that they are still developing processes to comply with the legislation and to integrate family caregivers into hospital systems and processes. CONCLUSIONS Our findings suggest that hospitals are complying with the legislation, while fully operationalizing the components of the CARE Act is a work in progress.
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Affiliation(s)
- Juleen Rodakowski
- Departments of Occupational Therapy, School of Health and Rehabilitation Sciences (Dr Rodakowski) and Acute and Tertiary Care, School of Nursing (Dr Martsolf), University of Pittsburgh, Pittsburgh, Pennsylvania; Clinical and Translational Science Institute, Pittsburgh, Pennsylvania (Dr Rodakowski); AmeriHealth Caritas Family of Companies, Philadelphia, Pennsylvania (Dr Leighton); RAND Corporation, Pittsburgh, Pennsylvania (Dr Martsolf); and Health Policy Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr James)
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17
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Martsolf GR, Komadino A, Germack H, Harrison J, Poghosyan L. Practice environment, independence, and roles among DNP- and MSN-prepared primary care nurse practitioners. Nurs Outlook 2021; 69:953-960. [PMID: 34446293 DOI: 10.1016/j.outlook.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 06/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many nursing schools are adopting the Doctor of Nursing Practice (DNP) as the preferred model of nurse practitioner (NP) education and eliminating Master of Science in Nursing (MSN) programs. To date, no studies have explored the relationship between DNP preparation and NP practice environment, independence, and roles. PURPOSE The purpos of this study is to compare practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. METHODS This study used a cross-sectional design and observational regression analysis of survey data. FINDINGS DNP-prepared NPs reported: 1) more favorable NP-Physician Relationships, 2) fewer clinical hours, and 3) more practice leadership. These differences were, however, small and not significant at 0.05 level. DISCUSSION We found no major differences in practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. As more nursing schools establish DNP programs and more DNP-prepared NPs enter the field, it is especially important to continue to study the impact of DNP preparation on the NP workforce.
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Affiliation(s)
- Grant R Martsolf
- University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA 15213; RAND Corporation, Health Care Division, Pittsburgh, PA 15213.
| | - Amy Komadino
- University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA 15213
| | - Hayley Germack
- University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA 15213
| | - Jordan Harrison
- RAND Corporation, Health Care Division, Pittsburgh, PA 15213
| | - Lusine Poghosyan
- Columbia University, School of Nursing, Center for Healthcare Delivery Research & Innovations, New York, NY
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18
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Gigli KH, Martsolf GR. Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles. Policy Polit Nurs Pract 2021; 22:221-229. [PMID: 34129414 PMCID: PMC10024928 DOI: 10.1177/15271544211021049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nurse practitioner (NP) advocacy efforts often focus on attaining full practice authority. While the effects of full practice authority in primary care are well described, implications for hospital-based NPs are less clear and may differ because of hospitals' team-based care and administrative structure. This study examines associations between state scope-of-practice (SSOP) and clinical roles of hospital-based pediatric intensive care unit (PICU) NPs. We conducted a national survey to assess clinical roles of PICU NPs including daily patient care, procedural, and consultation responsibilities as well as hospital-level administrative oversight practices. We classified SSOP as full or limited (reduced or restricted SSOP) practice. We present descriptive statistics and evaluate differences in clinical roles and hospital-level administrative oversight based on SSOP. The final sample included 55 medical directors and 58 lead (senior or supervisory) NPs from 93 of the 140 (66.4%) PICUs with NPs. There were no significant differences in daily patient care, procedural, or consultation responsibilities based on SSOP (p > .05). However, NPs in full practice authority states were more likely to bill for care than those in limited practice states (66.7% vs. 31.8%, p = .003), while those in limited practice states were more likely to report to advanced practice managers (36.7% vs. 13%, p = .03). For PICU NPs, SSOP was not associated with variation in clinical responsibilities; conversely, there were differences in billing and reporting practices. Future work is needed to understand implications of variation in hospital-level administrative oversight.
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Affiliation(s)
- Kristin H. Gigli
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, United States
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, United States
- RAND Corporation, Pittsburgh, Pennsylvania, United States
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19
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Germack HD, Mahmoud K, Cooper M, Vincent H, Koller K, Martsolf GR. Community socioeconomic disadvantage drives type of 30-day medical-surgical revisits among patients with serious mental illness. BMC Health Serv Res 2021; 21:653. [PMID: 34225719 PMCID: PMC8256502 DOI: 10.1186/s12913-021-06605-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with serious mental illness (SMI) are vulnerable to medical-surgical readmissions and emergency department visits. Methods We studied 1,914,619 patients with SMI discharged after medical-surgical admissions in Florida and New York between 2012 and 2015 and their revisits to the hospital within 30 days of discharge. Results Patients with SMI from the most disadvantaged communities had greater adjusted 30-day revisit rates than patients from less disadvantaged communities. Among those that experienced a revisit, patients from the most disadvantaged communities had 7.3 % greater 30-day observation stay revisits. Conclusions These results suggest that additional investments are needed to ensure that patients with SMI from the most disadvantaged communities are receiving appropriate post-discharge care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06605-y.
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Affiliation(s)
- Hayley D Germack
- University of Pittsburgh School of Nursing, 3500 Victoria Street 336 Victoria Building, 15261, Pittsburgh, PA, USA.
| | - Khadejah Mahmoud
- University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, 15261, Pittsburgh, PA, USA
| | - Mandy Cooper
- University of Pittsburgh School of Nursing, 3500 Victoria Street 336 Victoria Building, 15261, Pittsburgh, PA, USA
| | - Heather Vincent
- Community College of Allegheny County, 710 Duncan Avenue, 15237, Pittsburgh, PA, USA
| | - Krista Koller
- University of Pittsburgh College of General Studies, 1400 Wesley W. Posvar Hall 230 S. Bouquet St, 15260, PA, Pittsburgh, USA
| | - Grant R Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria Street 336 Victoria Building, 15261, Pittsburgh, PA, USA.,RAND Corporation, 4570 Fifth Ave #600, 15213, Pittsburgh, PA, USA
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20
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Abstract
BACKGROUND Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models. OBJECTIVES We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs. RESEARCH DESIGN Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes. MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay. RESULTS The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay. CONCLUSIONS Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.
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Affiliation(s)
- Kristin H. Gigli
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Billie S. Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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21
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Germack HD, Kandrack R, Martsolf GR. Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists. Nurs Outlook 2021; 69:945-952. [PMID: 34183190 DOI: 10.1016/j.outlook.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care. PURPOSE We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce. METHOD Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs. FINDINGS Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs. DISCUSSION We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.
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Affiliation(s)
- Hayley D Germack
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, PA.
| | - Ryan Kandrack
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Grant R Martsolf
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, PA; RAND Corporation, PA
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22
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Germack HD, Weissinger G, Bizhanova Z, Martsolf GR. Psychiatric Medication Changes Associated With Increased Rate of Medical Readmissions in Patients With Serious Mental Illness. J Nerv Ment Dis 2021; 209:166-173. [PMID: 33315795 DOI: 10.1097/nmd.0000000000001282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ABSTRACT To identify the impact of postdischarge psychiatric medication changes on general medical readmissions among patients with serious mental illness (SMI; bipolar disorder, major depressive disorder, and schizophrenia), claims from a 5% national sample of Medicare fee-for-service (FFS) beneficiaries hospitalized between 2013 and 2016 were studied. A total of 165,490 Medicare FFS beneficiaries with SMI 18 years or older with at least 1 year of continuous Medicare enrollment were identified. Within 30 days of discharge from index admission, 47.4% experienced a psychiatric medication change-including 75,892 beneficiaries experiencing a deletion and 55,713 experiencing an addition. After adjusting for potential confounders, those with a medication change experienced an 10% increase in the odds of 30-day readmission (odds ratio, 1.10; SE, 0.019; p < 0.001). Comorbid drug use disorder was also associated with an increased odds of readmission after controlling for other covariates. These findings suggest important factors that clinicians should be aware of when discharging patients with SMI.
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Affiliation(s)
- Hayley D Germack
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh
| | - Guy Weissinger
- Drexel University College of Nursing and Health Professions, Philadelphia
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23
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Belsky MA, Konanur A, Sim E, Yan A, Shaffer AD, Williams K, Martsolf GR, Chi D, Jabbour N. Advanced Practice Provider Clinics: Expediting Care For Children Undergoing Tympanostomy Tube Placement. Laryngoscope 2021; 131:2133-2140. [PMID: 33635578 DOI: 10.1002/lary.29477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/07/2021] [Accepted: 02/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE/HYPOTHESIS Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type. METHODS Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were <18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests. RESULTS A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P < .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P < .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification. CONCLUSIONS Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2133-2140, 2021.
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Affiliation(s)
- Michael A Belsky
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Anisha Konanur
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Edward Sim
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Annie Yan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Amber D Shaffer
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Kathryn Williams
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Grant R Martsolf
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, U.S.A
| | - David Chi
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Noel Jabbour
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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24
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Cohen CC, Barnes H, Buerhaus PI, Martsolf GR, Clarke SP, Donelan K, Tubbs-Cooley HL. Top priorities for the next decade of nursing health services research. Nurs Outlook 2020; 69:265-275. [PMID: 33386144 DOI: 10.1016/j.outlook.2020.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/28/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.
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Affiliation(s)
| | - Hilary Barnes
- University of Delaware, School of Nursing, Newark, DE
| | - Peter I Buerhaus
- Center for Interdisciplinary Health Workforce Studies, Montana State University College of Nursing, Bozeman, MT
| | - Grant R Martsolf
- University of Pittsburgh School of Nursing, Department of Acute and Tertiary Care, RAND Corporation, Pittsburgh, PA
| | - Sean P Clarke
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Karen Donelan
- Health Policy Research Center, The Mongan Institute, Survey Research and Implementation Unit, Harvard Medical School, Boston, MA
| | - Heather L Tubbs-Cooley
- Martha S. Pitzer Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus, OH
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25
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Harrison JM, Germack HD, Poghosyan L, Martsolf GR. Surveying Primary Care Nurse Practitioners: An Overview of National Sampling Frames. Policy Polit Nurs Pract 2020; 22:6-16. [PMID: 33225811 DOI: 10.1177/1527154420976081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nurse practitioners (NPs) represent the fastest growing segment of the U.S. primary care workforce. Surveys of primary care NPs can help to better understand the care NPs deliver across different health care settings, the factors that impact NP job satisfaction and burnout, and the structural capabilities required to support their practice. The purpose of this article is to provide an overview of national sampling frames that can be used by researchers interested in surveying or studying the U.S. primary care NP workforce. We conducted an environmental scan and review of published literature on the NP workforce to identify data sources that can be used to sample primary care NPs. In this article, we (a) identify the data elements needed to develop an NP sampling frame and (b) describe national data sets that can be used to sample primary care NPs, including the strengths and weaknesses of each. This information is intended to facilitate research on the primary care NP workforce to inform practice and policy.
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Affiliation(s)
| | - Hayley D Germack
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, United States
| | - Lusine Poghosyan
- Columbia University School of Nursing, New York City, New York, United States
| | - Grant R Martsolf
- RAND Corporation, Pittsburgh, Pennsylvania, United States.,Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, United States
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26
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Germack HD, Harrison J, Poghosyan L, Martsolf GR. Practice Patterns, Work Environments, and Job Outcomes of Rural and Urban Primary Care Nurse Practitioners. Med Care Res Rev 2020; 79:161-170. [PMID: 33213271 DOI: 10.1177/1077558720974537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.
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Affiliation(s)
| | | | | | - Grant R Martsolf
- University of Pittsburgh, Pittsburgh, PA, USA.,RAND Corporation, Pittsburgh, PA, USA
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27
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Martsolf GR, Gigli KH, Reynolds BR, McCorkle M. Misalignment of specialty nurse practitioners and the Consensus Model. Nurs Outlook 2020; 68:385-387. [PMID: 32593461 PMCID: PMC10024529 DOI: 10.1016/j.outlook.2020.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 10/24/2022]
Abstract
Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.
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Affiliation(s)
- Grant R Martsolf
- Professor, University of Pittsburgh, School of Nursing, Acute and Tertiary Care Department, Pittsburgh, PA; Affiliated Adjunct Policy Researcher, RAND Corporation, RAND Health Care, Pittsburgh, PA.
| | - Kristin H Gigli
- Post-doctoral Scholar, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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28
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Gigli KH, Davis BS, Yabes JG, Chang CCH, Angus DC, Hershey TB, Marin JR, Martsolf GR, Kahn JM. Pediatric Outcomes After Regulatory Mandates for Sepsis Care. Pediatrics 2020; 146:peds.2019-3353. [PMID: 32605994 PMCID: PMC7329251 DOI: 10.1542/peds.2019-3353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2013, New York introduced regulations mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment. METHODS We used hospital discharge data from 2011 to 2015 to compare changes in pediatric sepsis outcomes in New York and 4 control states: Florida, Massachusetts, Maryland, and New Jersey. We examined the effect of the New York regulations on 30-day in-hospital mortality using a comparative interrupted time-series approach, controlling for patient and hospital characteristics and preregulation temporal trends. RESULTS We studied 9436 children admitted to 237 hospitals. Unadjusted pediatric sepsis mortality decreased in both New York (14.0% to 11.5%) and control states (14.4% to 11.2%). In the primary analysis, there was no significant effect of the regulations on mortality trends (differential quarterly change in mortality in New York compared with control states: -0.96%; 95% confidence interval [CI]: -1.95% to 0.02%; P = .06). However, in a prespecified sensitivity analysis excluding metropolitan New York hospitals that participated in earlier sepsis quality improvement, the regulations were associated with improved mortality trends (differential change: -2.08%; 95% CI: -3.79% to -0.37%; P = .02). The regulations were also associated with improved mortality trends in several prespecified subgroups, including previously healthy children (differential change: -1.36%; 95% CI: -2.62% to -0.09%; P = .04) and children not admitted through the emergency department (differential change: -2.42%; 95% CI: -4.24% to -0.61%; P = .01). CONCLUSIONS Implementation of statewide sepsis regulations was generally associated with improved mortality trends in New York State, particularly in prespecified subpopulations of patients, suggesting that the regulations were successful in affecting sepsis outcomes.
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Affiliation(s)
- Kristin H. Gigli
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine
| | - Billie S. Davis
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine,,Departments of Biostatistics and
| | - Chung-Chou H. Chang
- Division of General Internal Medicine, Department of Medicine,,Departments of Biostatistics and,Health Policy and Management, Graduate School of Public Health, and
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine,,Health Policy and Management, Graduate School of Public Health, and
| | | | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania; and,RAND Corporation, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine,,Health Policy and Management, Graduate School of Public Health, and
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29
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Martsolf GR, Nuckols TK, Fingar KR, Barrett ML, Stocks C, Owens PL. Nonspecific chest pain and hospital revisits within 7 days of care: variation across emergency department, observation and inpatient visits. BMC Health Serv Res 2020; 20:516. [PMID: 32513147 PMCID: PMC7278151 DOI: 10.1186/s12913-020-05200-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/08/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Grant R Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria St, 315B, Pittsburgh, PA, 15213, USA.,RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.,Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker 113, Los Angeles, CA, 90048, USA
| | - Kathryn R Fingar
- IBM Watson Health, 5425 Hollister Ave, Suite 140, Santa Barbara, CA, 93111, USA
| | | | - Carol Stocks
- Affiliation during this investigation: Agency for Healthcare Research and Quality, Rockville, Maryland, USA.,Present address: West Virginia University, School of Public Health, 64 Medical Center Drive, PO Box 9190, Morgantown, WV, 26506-9190, USA
| | - Pamela L Owens
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD, 20857, USA.
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30
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Friedberg MW, Martsolf GR, Tomoaia-Cotisel A, Mendel P, McBain RK, Raaen L, Kandrack R, Qureshi NS, Etchegaray JM, Briscombe B, Hussey PS. Practice Expenses Associated with Comprehensive Primary Care Capabilities. Rand Health Q 2020; 9:2. [PMID: 32742744 PMCID: PMC7371356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care.
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Baird M, O'Donnell JM, Martsolf GR. Effects of opting-out from federal nurse anesthetists' supervision requirements on anesthesiologist work patterns. Health Serv Res 2019; 55:54-62. [PMID: 31835283 DOI: 10.1111/1475-6773.13245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To estimate the impact of opting-out from Medicare supervision requirements for certified registered nurse anesthetists (CRNAs) on anesthesiologists' work patterns. DATA SOURCES/STUDY SETTING Secondary data from two national surveys of anesthesiologists and the Area Health Resource File. STUDY DESIGN We use a matching difference-in-difference regression which contrasts the change in work patterns for anesthesiologists in California, which dropped supervision requirements, to the change for similar anesthesiologists. Key outcome variables include the number of weekly hours worked, the type of work done, and type of care delivery teams. DATA COLLECTION/EXTRACTION METHODS Self-reported national survey data drawn from members of the American Society of Anesthesiologists. PRINCIPAL FINDINGS Anesthesiologists in California saw no change in time spent working or time spent supervising CRNAs. There was a decrease in direct care clinical work hours along with a shift in working more in intraoperative care, a decrease in postoperative care, and an increase in the percentage of cases supervising residents. CONCLUSIONS Anesthesiologists had small but real responses to California's decisions to opt-out of the physician supervision requirement for CRNAs, doing more work in intraoperative care and less outside of the operating room. Total hours worked saw no change.
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Affiliation(s)
| | - John M O'Donnell
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Grant R Martsolf
- RAND Corporation, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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Martsolf GR, Kandrack R, Rodakowski J, Friedman EM, Beach S, Folb B, James AE. Work Performance Among Informal Caregivers: A Review of the Literature. J Aging Health 2019; 32:1017-1028. [DOI: 10.1177/0898264319895374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To examine the association between informal caregiving and caregiver work performance. Method: A systematized review of the literature. Results: We found that caregiving has an adverse impact on work performance: caregivers experience substantial work disruptions and negative work performance outcomes, and these findings were consistent across measures. Our synthesis suggests that caregivers miss a significant amount of work and have reductions in productivity due to their caregiving responsibilities. However, significant methodological limitations with the reviewed studies make systematic interpretations and causal determinations challenging. Discussion: Examining the effect of caregiving on work performance is critical to better understand the full impact of caregiving, especially as demand for caregivers increases as the population ages. This comprehensive review suggests that caregiving has a significant negative impact on work performance, although methodological challenges remain in this area of science. These findings should inform both public policy development and workplace benefits design.
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Affiliation(s)
- Grant R. Martsolf
- RAND Corporation, Pittsburgh, PA, USA
- University of Pittsburgh, PA, USA
| | - Ryan Kandrack
- RAND Corporation, Pittsburgh, PA, USA
- The University of North Carolina at Chapel Hill, USA
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Affiliation(s)
- Hayley Drew Germack
- Hayley Drew Germack is an assistant professor of acute and tertiary care at the University of Pittsburgh School of Nursing, in Pennsylvania
| | - Ryan Kandrack
- Ryan Kandrack is a PhD student in the Cecil G. Sheps Center for Health Services Research, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Grant R. Martsolf
- Grant R. Martsolf is a professor of acute and tertiary care at the University of Pittsburgh School of Nursing and an affiliated adjunct policy researcher at the RAND Corporation in Pittsburgh
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Abstract
Adopting full scope of practice (SOP) for nurse practitioners (NPs) is associated with improved access to care. One possible mechanism for these improvements is increased NP supply. Using county-level data, we fit cross-sectional and panel regression models to estimate the association between adopting full NP SOP and NP supply in general, and in rural and health professional shortage area-designated counties in particular. In cross-sectional analyses, we estimated positive associations between NP SOP and NP supply, though these relationships were only statistically significant when analyzing health professional shortage areas. In the panel regression models with county fixed effects, the estimated effects were attenuated toward zero and sometimes switched signs. Our findings suggest that improvements in access to care following adoption of full SOP may not be driven by increased NP supply but rather by increased capacity of NPs and physicians to provide care.
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Affiliation(s)
- Ryan Kandrack
- University of North Carolina at Chapel Hill, NC, USA.,RAND Corporation, Pittsburgh, PA, USA
| | | | - Grant R Martsolf
- RAND Corporation, Pittsburgh, PA, USA.,University of Pittsburgh, Pittsburgh, PA, USA
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Martsolf GR, Sochalski J. The Need for Advanced Clinical Education for Nurse Practitioners Continues Despite Expansion of Doctor of Nursing Practice Programs. Policy Polit Nurs Pract 2019; 20:183-185. [PMID: 31640458 DOI: 10.1177/1527154419882310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We read with great interest Mundinger and Carter's exposition of how, in their view, Doctor of Nursing Practice (DNP) education has lost its way and what consequences might result. Mundinger and Carter note that DNP programs are overwhelming focused on nonclinical practice. We share the concern of Mundinger and Carter about the future of nurse practitioner (NP) education within the context of expanding DNP programs. In this commentary, we raise concerns about NP transition to practice and the limited, but concerning, evidence that new NPs struggle in their transition to practice. We note that this concern is magnified as NPs continue to move into specialty roles. Health systems have responded to this concern by developing residency and fellowship programs. Fifteen years after the AACN position statement on the clinical doctorate was issued, the goal of DNP education remains an unfinished project. An important question remains: Can, will, and how should DNP programs deliver?
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Affiliation(s)
- Grant R Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, PA, USA
- RAND Corporation, RAND Health Care, Santa Monica, CA, USA
| | - Julie Sochalski
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Friedman EM, Rodakowski J, Schulz R, Beach SR, Martsolf GR, James AE. Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers. Gerontologist 2019; 59:e535-e551. [PMID: 30945725 DOI: 10.1093/geront/gny182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie. RESEARCH DESIGN AND METHODS A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature. RESULTS Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed. DISCUSSION AND IMPLICATIONS The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.
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Affiliation(s)
| | - Juleen Rodakowski
- Department of Occupational Therapy, University of Pittsburgh, Pennsylvania
| | - Richard Schulz
- Department of Psychiatry, University of Pittsburgh, Pennsylvania
| | - Scott R Beach
- University Center for Social and Urban Research, University of Pittsburgh, Pennsylvania
| | - Grant R Martsolf
- RAND Corporation, Santa Monica, California.,School of Nursing, University of Pittsburgh, Pennsylvania
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Kahn JM, Davis BS, Yabes JG, Chang CCH, Chong DH, Hershey TB, Martsolf GR, Angus DC. Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis. JAMA 2019; 322:240-250. [PMID: 31310298 PMCID: PMC6635905 DOI: 10.1001/jama.2019.9021] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. OBJECTIVE To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. EXPOSURES Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay. RESULTS The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001). CONCLUSIONS AND RELEVANCE In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.
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Affiliation(s)
- Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David H. Chong
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Tina Batra Hershey
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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38
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Martsolf GR, Hall D. Is a culture of health always healthy? Nurs Forum 2019; 54:392-395. [PMID: 30908674 DOI: 10.1111/nuf.12345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/28/2019] [Accepted: 03/09/2019] [Indexed: 06/09/2023]
Abstract
Health care systems in the United States are increasingly focused on addressing the social and cultural determinants of health (ie, a biopsychosocial model of disease). We applaud this important and laudable shift within US healthcare, which has long been dominated by a merely biomedical model of disease. However, we offer three reasons for nurses and other healthcare providers to proceed with caution; otherwise, human culture could become merely a tool of the healthcare industry to be instrumentally deployed in meeting its procedural goals.
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Affiliation(s)
- Grant R Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- RAND Health Care, RAND Corporation, Pittsburgh, Pennsylvania
| | - Daniel Hall
- Department of Surgery, School of Medicine, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Wolff Center at UPMC, University of Pittsburgh, University of Pittsburgh Medical Centers, Pittsburgh, Pennsylvania
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Affiliation(s)
- Ryan Kandrack
- RAND Corporation, Pittsburgh, PA, USA. .,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Grant R Martsolf
- RAND Corporation, Pittsburgh, PA, USA.,University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Rachel O Reid
- RAND Corporation, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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40
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Martsolf GR, Kandrack R, Friedberg MW, Briscombe B, Hussey PS, LaBonte C. Estimating the Costs of Implementing Comprehensive Primary Care: A Narrative Review. Health Serv Res Manag Epidemiol 2019; 6:2333392819842484. [PMID: 31069248 PMCID: PMC6492354 DOI: 10.1177/2333392819842484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 11/15/2022] Open
Abstract
The performance of the any health-care system relies on a high-functioning primary care system. Increasing primary care practices' adoption of "comprehensive primary care" capabilities might yield meaningful improvements in the quality and efficiency of primary care. However, many comprehensive primary care capabilities, such as care management and coordination, are not compensated via traditional fee-for-service payment. To calculate new payments for these capabilities, policymakers would need estimates of the costs that practices incur when adopting, maintaining, and using the capabilities. We performed a narrative review of the existing literature on the costs of adopting and implementing comprehensive primary care capabilities. These studies have found that practices incur significant costs when adopting and implementing comprehensive primary care capabilities. However, the studies had significant limitations that prevent extensive use of their estimates for payment policy. Particularly, the strongest studies focused on a small numbers of practices in specific geographic areas and the concepts and methods used to assess costs varied greatly across the studies. Furthermore, none of the studies in our review attempted to estimate differences in costs across practices with patients at varying levels of complexity and illness burden which is important for risk-adjusting payments to practices. Therefore, due to the heterogeneous designs and limited generalizability of published studies highlight the need for additional research, especially if payers wish to link their financial support for comprehensive primary care capabilities to the costs of these capabilities for primary care practices.
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Affiliation(s)
- Grant R Martsolf
- RAND Corporation, Pittsburgh, PA, USA.,Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ryan Kandrack
- RAND Corporation, Pittsburgh, PA, USA.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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Mason DJ, Martsolf GR, Sloan J, Villarruel A, Sullivan C. Making health a shared value: Lessons from nurse-designed models of care. Nurs Outlook 2019; 67:213-222. [DOI: 10.1016/j.outlook.2018.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/13/2018] [Accepted: 12/21/2018] [Indexed: 11/28/2022]
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Poghosyan L, Timmons EJ, Abraham CM, Martsolf GR. The Economic Impact of the Expansion of Nurse Practitioner Scope of Practice for Medicaid. Journal of Nursing Regulation 2019. [DOI: 10.1016/s2155-8256(19)30078-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = −0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = −0.48, P = .015) and less proactive patient outreach (β = −1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs.
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Affiliation(s)
- Grant R Martsolf
- 1 University of Pittsburgh, PA, USA.,2 RAND Corporation, Pittsburgh, PA, USA
| | | | - Mark W Friedberg
- 2 RAND Corporation, Pittsburgh, PA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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Abstract
Twenty-first century America is marked by deep and seemingly incommensurable divisions in terms of public policy solutions to our most intractable issues. Health policy challenges are not immune to these deep divisions, as the debate during and since the passage of the Affordable Care Act illustrates. Positions on key public policy issues are driven by largely implicit and unarticulated philosophical presuppositions that guide individuals' notions of the nature of government, individuals' moral obligations to each other, how society assesses quality of life, and what it means to be a community. If faculty in schools of nursing are to prepare graduate nurses to enter into these heated public policy debates, we must help students understand, identify, and articulate the philosophical presuppositions that undergird reasoning related to health policy issues. In this article, we present a working taxonomy that can help faculty members provide students with a basic understanding of core philosophical principles. We attempt to categorize all of western political philosophy into four distinct traditions or "impulses," describing each of these four traditions in detail. We illustrate each tradition's approach to political reasoning using a specific health policy case study. We conclude with some guidance about how to implement this content within a doctoral-level public policy curriculum.
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Affiliation(s)
- Grant R Martsolf
- 1 School of Nursing, University of Pittsburgh, PA, USA
- 2 RAND Corporation, Pittsburgh, PA, USA
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45
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Abstract
This study examines trends in advanced practice clinician employment across different physician practices in the United States.
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Affiliation(s)
- Grant R Martsolf
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania.,RAND Corporation, Pittsburgh, Pennsylvania
| | - Hilary Barnes
- School of Nursing, University of Delaware, Newark, Delaware
| | - Michael R Richards
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristin N Ray
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Heather M Brom
- Center for Healthcare Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew D McHugh
- Center for Healthcare Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
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46
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Affiliation(s)
- Grant R. Martsolf
- University of Pittsburgh, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | | | | | - Diana Mason
- George Washington University School of Nursing, Washington, DC, USA
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Abstract
Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and NP-administration relationships; organizational support and governance; time and space for teamwork; and regulations and economic impact as important. Practice and policy change addressing these factors is needed for effective interprofessional teamwork.
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Affiliation(s)
- Lusine Poghosyan
- Columbia University School of Nursing, New York (Dr Poghosyan and Ms Norful); and RAND Corporation, Pittsburgh, Pennsylvania (Dr Martsolf)
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48
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Schulz R, Beach SR, Friedman EM, Martsolf GR, Rodakowski J, James AE. Changing Structures and Processes to Support Family Caregivers of Seriously Ill Patients. J Palliat Med 2017; 21:S36-S42. [PMID: 29091533 DOI: 10.1089/jpm.2017.0437] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although family caregivers provide a significant portion of health and support services to adults with serious illness, they are often marginalized by existing healthcare systems and procedures. OBJECTIVE We examine the role of caregivers in existing systems of care, identify needed changes in structures and processes, and describe how these changes might be monitored and assessed and who should be accountable for implementing them. DESIGN Based on a broad assessment of the caregiving literature, the recent National Academy of Sciences Report on family caregiving, and descriptive data from two national surveys, we describe structural and process barriers that limit caregivers' ability to provide effective care. SUBJECTS To describe the unique challenges and impacts of caring for seriously ill patients, we report data from a nationally representative sample of older adults and their caregivers (National Health and Aging Trends Study [NHATS]; National Study of Caregiving [NSOC]) to identify the prevalence and impact on family caregivers of seriously ill patients who have high needs for support and are high cost to the healthcare system. MEASUREMENTS Standardized measures of patient status and caregiver roles and impacts are used. RESULTS Multiple structural and process barriers limit the ability of caregivers to provide effective care. These issues are exacerbated for the more than 13 million caregivers who provide care and support to 9 million seriously ill older adults. CONCLUSIONS Fundamental changes are needed in the way we identify, assess, and support caregivers. Educational and workforce development reforms are needed to enhance the competencies of healthcare and long-term service providers to effectively engage caregivers.
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Affiliation(s)
- Richard Schulz
- 1 Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Scott R Beach
- 2 University Center for Social and Urban Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Esther M Friedman
- 3 Pardee RAND Graduate School, RAND Corporation , Santa Monica, California
| | - Grant R Martsolf
- 4 Pardee RAND Graduate School, RAND Corporation , Pittsburgh, Pennsylvania
| | - Juleen Rodakowski
- 5 Department of Occupational Therapy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - A Everette James
- 6 Health Policy Institute, University of Pittsburgh , Pittsburgh, Pennsylvania
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49
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Abstract
This analysis of published evaluations of medical home interventions investigates whether there is an association between the findings and whether the evaluators were employed or funded by intervention sponsors.
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Affiliation(s)
- Anna Oh
- Division of Geriatrics, Department of Medicine, University of California-San Francisco
| | | | - Mark W Friedberg
- RAND Corporation, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
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50
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Ray KN, Martsolf GR, Mehrotra A, Barnett ML. Trends in Visits to Specialist Physicians Involving Nurse Practitioners and Physician Assistants, 2001 to 2013. JAMA Intern Med 2017; 177:1213-1216. [PMID: 28586817 PMCID: PMC5818794 DOI: 10.1001/jamainternmed.2017.1630] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study describes the roles of nurse practitioners and physician assistants in providing care to specialist physicians’ patients.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant R Martsolf
- RAND Corporation and Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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