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Ma B, Park YJ, Han J, Gandhi M, Ramien M, Klassen D, Payant L, Rose E, Garber G, Probst M, Hardin J. Medico-Legal Complaints Against Dermatologists: Data From the Canadian Medical Protective Association, 2013 to 2022. J Cutan Med Surg 2024:12034754241275989. [PMID: 39315521 DOI: 10.1177/12034754241275989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
BACKGROUND Medico-legal complaints against physicians are a significant source of anxiety and could be associated with defensive medical practices that may correlate with poor patient outcomes. Little is known about patient concerns brought to regulatory bodies and courts against dermatologists in Canada. OBJECTIVE To characterize factors contributing to medico-legal complaints brought against dermatologists in Canada. METHODS The Canadian Medical Protective Association (CMPA) repository was queried for all closed cases involving dermatologists over the past decade. Aggregate, anonymized data was reviewed and case outcomes, patient harm, and contributing factors were extracted. RESULTS Nearly one-fifth of all dermatologists who are CMPA members have been named in at least one medico-legal case between 2013 to 2022. A total of 396 civil-legal actions or College complaint cases involving dermatologists were closed at the CMPA during this timeframe. The most common patient allegations were deficient assessment (34%), diagnostic error (28%), and unprofessional manner (22%). Nearly half of patients experienced a harmful event, the majority of which were asymptomatic or mild. The most frequently identified contributing factors related to providers were poor clinical decision making (n = 73), lack of situational awareness (n = 67), and conduct and boundary issues (n = 59). Team factors included a breakdown of communication with patients (n = 124). CONCLUSIONS Improved communication with patients for informed consent, treatment plans, clinical follow-up, and documentation of thorough clinical patient assessments can improve patient satisfaction and health outcomes, and mitigate dermatologists' medico-legal risk.
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Affiliation(s)
- Bryan Ma
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ye-Jean Park
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jing Han
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maharshi Gandhi
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michele Ramien
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Community Pediatrics, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Klassen
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura Payant
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Elaine Rose
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Gary Garber
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mireille Probst
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Jori Hardin
- Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Hu X, Coplan B, Barnes H, Smith N, Essary A, Dill M. Physicians working with physician assistants and nurse practitioners: perceived effects on clinical practice. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae070. [PMID: 38919965 PMCID: PMC11196955 DOI: 10.1093/haschl/qxae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/06/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024]
Abstract
Physicians in the United States are increasingly working with physician assistants (PAs) and nurse practitioners (NPs), but little is known about how they perceive working with PAs and NPs affects their clinical practice. We used a new national survey to examine physicians' perceptions of working with PAs and/or NPs on their patient volume, care quality, time use, and workload. Among our analytical sample of 5823 physicians, 59% reported working with PAs and/or NPs. Most reported that PAs and NPs positively affected their clinical practice. Among several findings, physicians working in medical schools and with higher incomes were more likely to indicate that PAs improve their clinical practices in all 4 aspects, while being in specialties with higher women's representation was associated with lower ratings for working with PAs. Native Hawaiian and Pacific Islander physicians and those with higher incomes were more likely to signify that NPs improved their clinical practices in all 4 aspects. These findings provide valuable insights, from the physicians' perspective, on care delivery reform.
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Affiliation(s)
- Xiaochu Hu
- Association of American Medical Colleges, Workforce Studies, Washington, DC 20001, United States
| | - Bettie Coplan
- Northern Arizona University, College of Health and Human Services, Phoenix, AZ 85004, United States
| | - Hilary Barnes
- Widener University, School of Nursing, Chester, PA 19013, United States
| | - Noël Smith
- American Academy of Physician Associates, Research Department, Alexandria, VA 22314, United States
| | - Alison Essary
- Northern Arizona University, College of Health and Human Services, Phoenix, AZ 85004, United States
| | - Michael Dill
- Association of American Medical Colleges, Workforce Studies, Washington, DC 20001, United States
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Forman K, Bruno CJ, Izatt S, Fuloria M, Adams A, Kim M, Zuber J, Cano N, LaTuga MS. Building Relationships: Advanced Practice Providers and Fellows in Neonatal-Perinatal Medicine. Am J Perinatol 2024; 41:e2514-e2520. [PMID: 37541311 DOI: 10.1055/s-0043-1771503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
OBJECTIVE Advanced practice providers (APPs) are a critical component of health care teams, especially in the neonatal intensive care unit. At times, APPs and neonatal-perinatal medicine (NPM) fellows may experience tension in their professional relationship. They may perceive the other's performance and abilities differently. We hypothesized that satisfaction with the APP-NPM fellow interprofessional relationship would be associated with higher perception of APP competence by NPM fellows. STUDY DESIGN We surveyed 274 medical providers: NPM fellows (24.8%), NPM program directors (24.5%), and APPs (50.7%). APPs were defined as neonatal nurse practitioners, pediatric nurse practitioners, physician assistants, or neonatal hospitalists. We obtained demographic data, information about sources of conflict in the APP-NPM fellow relationship, level of satisfaction with the relationship, and targeted interventions for improvement. NPM fellow perception of APP competence as well as APP self-assessed competence were elicited. Statistical analyses were performed with chi-square tests and Fisher's exact tests. RESULTS Overall, APPs and NPM fellows were generally satisfied with their relationship. All groups reported APP competence as equivalent to a third-year NPM fellow. NPM fellow perception of APP competence increased with year of fellow training. Higher perceived APP competence by NPM fellows correlated with higher relationship satisfaction scores. Difficulties with teamwork, communication and respect were associated with lower satisfaction within the APP-NPM fellow relationship. CONCLUSION The professional working dynamic between these two groups is viewed positively by all. Satisfaction with the APP-NPM fellow relationship correlated with higher perception of APP competence by NPM fellows. Targeted interventions that increase NPM fellow perception of APP competence and ameliorate the difficulties encountered in the APP-NPM fellow relationship may improve this interprofessional relationship. KEY POINTS · Advanced practice providers and NPM fellows may have similar responsibilities leading to challenges.. · NPM fellows with higher perceived competence of APPs had higher satisfaction with their relationship.. · Training APPs to teach, creating interprofessional education, and routine debrief sessions may help..
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Affiliation(s)
- Katie Forman
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Christie J Bruno
- Division of Neonatology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Susan Izatt
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Mamta Fuloria
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Aaron Adams
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Jennifer Zuber
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Nefertiti Cano
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Mariam S LaTuga
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Shiau C, Kim DY, Young PA, Baker A, Bae GH. Trends in dermatologic procedures performed by dermatologists and advanced practice clinicians among Medicare beneficiaries from 2012 to 2020. J Am Acad Dermatol 2024; 90:1054-1057. [PMID: 38242175 DOI: 10.1016/j.jaad.2023.12.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/22/2023] [Accepted: 12/30/2023] [Indexed: 01/21/2024]
Affiliation(s)
| | | | - Peter A Young
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California; Department of Dermatology, The Permanente Medical Group, Sacramento, California
| | | | - Gordon H Bae
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California.
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Bork S, LeBar K. The implementation and impact of an advanced practice recognition program. J Am Assoc Nurse Pract 2024; 36:90-93. [PMID: 38127655 DOI: 10.1097/jxx.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/17/2023] [Indexed: 12/23/2023]
Abstract
ABSTRACT Meaningful job recognition is a pillar for sustaining healthy work environments and proven beneficial for job satisfaction and retention. However, few dedicated award recognition programs exist for advanced practice registered nurses (APRNs), and no available literature evaluates the impact on professional practice, sense of belonging, and job retention or satisfaction. The purpose of this study was to introduce a novel award recognition program for APRNs and physician associates (PAs) in a large academic medical system and evaluate it's impact on job satisfaction, retention, and sense of belonging. Five awards were created to recognize areas of achievement for clinically practicing APRNs or PAs within an academic health system. Nomination letters were collected, deidentified, and reviewed by an award committee. Winners were announced and received a plaque. A survey was sent to employed APRNs evaluating their response to the program. The survey was sent to both APRNs (83%) and PAs (17%). Survey end points included job satisfaction, willingness to stay in role for 1 and 5 years, sense of community, something to work toward, and increasing recognition of APRNs. Results showed statistical significance in three areas. Advanced practice registered nurses or PAs who were aware of award opportunities and/or nominated for an award showed higher job satisfaction, more likely to stay in job for 1 year, and felt a greater level of recognition. Dedicated APRN award programs may have a positive impact on job satisfaction and retention. This model may be extrapolated to provide greater opportunities for meaningful recognition among clinical APRNs.
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Affiliation(s)
| | - Kiersten LeBar
- MUSC Shawn Jenkins Children's Hospital, Charleston, South Carolina
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Pelletier B, Hoyt A. The Orthopaedic NP Workforce: Results From a Nationally Representative Survey. Orthop Nurs 2024; 43:32-40. [PMID: 38266262 DOI: 10.1097/nor.0000000000001000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Although a growing number of nurse practitioners (NPs) are practicing in orthopaedics, little is known about the workforce. The aim of this study was to estimate the size of the orthopaedic NP workforce, compare it with the workforce of primary care NPs, and investigate the interaction effect specialty NP practice and physician relationships have on NP role perception. We selected licensed, practicing orthopaedic and primary care NPs from the 2018 National Sample Survey of Registered Nurses and compared demographics, education, experience, functional autonomy, and job outcomes. Nationally, 2,796 NPs described their specialty as orthopaedics. Compared with primary care NPs, they spent 27% more time on care coordination, were half as likely to have their own patient panel, and were most likely to say that their NP education was fully utilized when in a collaborative relationship with physicians. Differences between orthopaedic and primary care NPs may call for reform of Consensus Model that currently places specialty practice outside its regulatory network.
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Affiliation(s)
- Brittany Pelletier
- Brittany Pelletier, AGPCNP-BC, ATC, Comprehensive Rehab Consultants, Boston, MA
- Alex Hoyt, PhD, RN, Associate Professor, School of Nursing, MGH Institute of Health Professions, Boston, MA
| | - Alex Hoyt
- Brittany Pelletier, AGPCNP-BC, ATC, Comprehensive Rehab Consultants, Boston, MA
- Alex Hoyt, PhD, RN, Associate Professor, School of Nursing, MGH Institute of Health Professions, Boston, MA
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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] [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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Crowley R, Pugach D, Williams M, Goldman J, Hilden D, Schultz AF, Beachy M. Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care: A Position Paper From the American College of Physicians. Ann Intern Med 2024; 177:65-67. [PMID: 38145573 DOI: 10.7326/m23-2260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams.
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Affiliation(s)
- Ryan Crowley
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - David Pugach
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - Margo Williams
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - Jason Goldman
- Charles E. Schmidt College of Medicine, Boca Raton, Florida (J.G.)
| | - David Hilden
- Hennepin Healthcare, Minneapolis, Minnesota (D.H.)
| | | | - Micah Beachy
- University of Nebraska Medical Center, Omaha, Nebraska (M.B.)
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Brom H, Poghosyan L, Nikpour J, Todd B, Sliwinski K, Franz T, Chittams J, Aiken L, Brooks Carthon M. Racial Disparities in Lipid Screening Among Patients With Coronary Artery Disease Narrowed in Primary Care Settings Supportive of Nurse Practitioners. JOURNAL OF NURSING REGULATION 2023; 14:20-32. [PMID: 39206146 PMCID: PMC11349328 DOI: 10.1016/s2155-8256(23)00110-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background Coronary artery disease (CAD) is the most prevalent heart disease in the United States, and it disproportionately affects Black compared to White patients. Regular primary care and dyslipidemia screening and management are essential for optimal CAD care. Nurse practitioners (NPs) increasingly provide primary care services, though unsupportive practice environments may constrain their ability to do so. Purpose To examine whether disparities in lipid screening between Black and White patients with CAD were associated with the NP practice environment scores. Methods Cross-sectional survey data from NPs in primary care practices and Medicare claims were linked to evaluate outcomes among 111,911 CAD patients (94% White, 6% Black) across 456 primary care practices in four states (California, Florida, New Jersey, and Pennsylvania) in 2016. The NP-Primary Care Organizational Climate Questionnaire, which provides a score on the supportiveness of a respondent's practice, was used to evaluate the NP practice environment. Multilevel regression models that accounted for patient and practice characteristics were used to evaluate the study aim. Results Compared to White patients with CAD, Black patients with CAD less frequently received annual lipid screening (77.0% vs. 70.6%; p < .001). In logistic regression models accounting for patient and practice characteristics, for every standard deviation increase in the practice environment score, Black patients experienced a 5% increase in odds of receiving lipid screening. Conclusion Investing in the NP practice environment, including increasing NP role visibility and strengthening relationships with physicians and administrators, may narrow racial disparities in CAD management.
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Affiliation(s)
- Heather Brom
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia
| | | | - Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Associate Fellow, Leonard Davis Institute of Health Economics
| | - Barbara Todd
- Practice & Education-Advanced Practice, Hospital of the University of Pennsylvania
| | - Kathy Sliwinski
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | | | | | - Linda Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
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Mohr C, Li Y, Hinkston CL, Margolis DJ, Wehner MR. Trends Over Time in Medicare for Advanced Practice Clinicians in Dermatology, 2013-2020. JAMA Dermatol 2023; 159:859-863. [PMID: 37405748 PMCID: PMC10323756 DOI: 10.1001/jamadermatol.2023.1843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/05/2023] [Indexed: 07/06/2023]
Abstract
Importance The number of advanced practice clinicians (APCs, including nurse practitioners and physician assistants) in the US is increasing. The effect this has on dermatology is unclear. Objective To develop a method to identify APCs practicing dermatology in claims data and to evaluate the contribution of dermatology APCs to the dermatology workforce and how this has changed over time. Design, Setting, and Participants This retrospective cohort study used the Medicare Provider Utilization and Payment Data Public Use files (2013 to 2020). As APCs are not listed by specialty, a method to identify APCs practicing dermatology was developed and validated using common dermatology procedural codes. The data were analyzed from November 2022 to April 2023. Main Outcomes and Measures The proportion of clinicians and office visits by dermatology APCs and physician dermatologists were evaluated using Mann-Kendall tests. Joinpoint analysis was also used to compare the average annual percentage change of dermatology procedures and clinicians in rural-urban areas between dermatology APCs and physician dermatologists. Results The method to identify APCs practicing dermatology had 96% positive predictive value, 100% negative predictive value, 100% sensitivity, and 100% specificity. Between 2013 and 2020, 8444 dermatology APCs and 14 402 physician dermatologists were identified. They provided 109 366 704 office visits in Medicare. The percentage of dermatology clinicians who were APCs increased over time, from 27.7% in 2013 to 37.0% in 2020 (P = .002). The proportion of dermatologic office visits provided by APCs also increased over time, from 15.5% in 2013 to 27.4% in 2020 (P = .002). For all procedure categories, the average annual percentage change was positive for dermatology APCs (range, 10.05%-12.65%) and was higher than that of physician dermatologists. For all rural-urban designations, the average annual percentage change was positive for dermatology APCs (range, 2.03%-8.69%) and was higher than metropolitan, micropolitan, and small-town areas from that of physician dermatologists. Conclusions and Relevance In this retrospective cohort study, there was a temporal increase in the amount of dermatologic care provided by APCs in Medicare. These findings demonstrate changes in the dermatology workforce and may have implications for dermatology as a specialty.
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Affiliation(s)
- Cassandra Mohr
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Yao Li
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Candice L. Hinkston
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - David J. Margolis
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mackenzie R. Wehner
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston
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11
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Hyman MJ, Skolarus TA, Litwack K, Meltzer DO, Modi PK. Outcomes of Hematuria Evaluation by Advanced Practice Providers and Urologists. Urology 2023; 178:67-75. [PMID: 37196831 DOI: 10.1016/j.urology.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To examine the quality and costs of care for patients evaluated for hematuria by urologic advanced practice providers (APPs) and urologists. The roles of APPs in urology are growing, but their clinical and financial outcomes compared to urologists are not well understood. METHODS We conducted a retrospective cohort study of commercially insured patients using data from 2014 to 2020. We included adult beneficiaries with a diagnosis code for hematuria and an initial outpatient evaluation and management visit with a urologic APP or urologist. We assessed receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within 6 months of the initial visit. Secondary outcomes included the time until each of these outcomes occurred and the out-of-pocket spending and total payments. RESULTS We identified 59,923 patients who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio [OR] 0.93, 95% confidence interval [95% CI] 0.54-0.72, P < .001), imaging studies (OR 0.79, 95% CI 0.69-0.91, P < .001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, P = .02). Visits with urologic physician assistants were associated with 11% greater out-of-pocket payments (incident risk ratio 1.11, CI 1.01-1.22, P = .02) and 14% greater total payments (incident risk ratio 1.14, CI 1.04-1.25, P = .004). CONCLUSION There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study, and specialty-specific training for APPs should be considered.
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Affiliation(s)
- Max J Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
| | - Kim Litwack
- College of Nursing, University of Wisconsin Milwaukee, Milwaukee, WI
| | - David O Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL; Departments of Medicine and Economics, Harris School of Public Policy Studies, University of Chicago, Chicago, IL
| | - Parth K Modi
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL; Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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12
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Koppolu R, Nandwani M, Navoa J, Kuriakose C. Advanced Practice Provider Onboarding: An Academic Teaching Institution's Experience. J Nurs Adm 2023; 53:326-330. [PMID: 37219884 DOI: 10.1097/nna.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
With the robust growth in demand for advanced practice providers (APPs), employers must focus on strategies to promote recruitment, retention, and job satisfaction. The authors describe the creation, development, and sustainability of an APP onboarding program to support the initial transition for providers into their new roles within an academic healthcare organization. Advanced practice provider leaders coordinate with multidisciplinary stakeholders to ensure new-hire APPs are equipped with the necessary tools for a successful start.
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Affiliation(s)
- Rajashree Koppolu
- Author Affiliations: Manager of Advanced Practice Professional Development (Koppolu), Center for Advanced Practice, Stanford Medicine Children's Health, Palo Alto; and Manager of Advanced Practice Providers (Dr Nandwani and Navoa) and Executive Director of Advanced Practice (Kuriakose), Center for Advanced Practice, Stanford Medicine Health Care, Stanford, California
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13
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Martsolf G, Turi E, Liu J, Chen J, Poghosyan L. DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions. Nurs Outlook 2023; 71:101951. [PMID: 36947974 PMCID: PMC10683711 DOI: 10.1016/j.outlook.2023.101951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Many professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes. PURPOSE To examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs. METHODS We use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship. RESULS We find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs. DISCUSSION These findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes. CONCLUSIONS Further empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.
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Affiliation(s)
- Grant Martsolf
- School of Nursing, University of Pittsburgh, Pittsburgh, PA.
| | - Eleanor Turi
- School of Nursing, Columbia University, New York, NY
| | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY
| | - Julius Chen
- Mailman School of Public Health, Columbia University, New York, NY
| | - Lusine Poghosyan
- School of Nursing, Columbia University, New York, NY; Mailman School of Public Health, Columbia University, New York, NY
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14
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McCutcheon T. Colorectal surgery NP fellowship: A transition to autonomy. Nurse Pract 2023; 48:32-37. [PMID: 36975748 DOI: 10.1097/01.npr.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
ABSTRACT The colorectal surgery advanced practice fellowship was developed for the purpose of providing a successful transition to the colorectal advanced practice specialty and was based on the success of the NP utilization model. The success of the fellowship led to NP practice autonomy, job satisfaction, and retention.
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Affiliation(s)
- Tonna McCutcheon
- Tonna McCutcheon is an NP in surgery at Vanderbilt Colon and Rectal Surgery, Vanderbilt University, Nashville, Tenn
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15
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Self-reported factors contributing to delay in ALS diagnosis among primary care providers in a large Ohio-based US healthcare network. J Neurol Sci 2023; 445:120532. [PMID: 36628902 DOI: 10.1016/j.jns.2022.120532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/08/2022] [Accepted: 12/20/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study's primary objective is to identify self-reported factors that contribute to diagnostic delay in ALS among Primary Care Providers (PCPs). METHODS A de novo email-based survey was deployed to Ohio-based PCPs in the Cleveland Clinic Health System. RESULTS Of the 77 PCP participants [including 30 Advance Practice Providers (APPs)] only: (a) 18% of physicians, and 3% of APPs were very confident or confident with recognizing signs and symptoms of ALS, (b) 13% of physicians, and 21% of APP s felt very confident or confident with distinguishing between a neurologic cause of dysfunction from other possible causes, and (c) 23% of physicians, and 11% of APPs felt very confident or confident with distinguishing between upper and lower motor neuron signs. If presented with a weak patient without a specific diagnosis, PCPs most frequently ordered electrodiagnostic testing, brain MRI, cervical or thoracic spine MRI, and serum creatine kinase. PCPs identified top reasons for delayed ALS diagnosis as: (a) patient's delay in seeking medical help, (b) diagnostic uncertainty (c) waiting time for neurology/neuromuscular medicine (NM) consultation. The most desired strategies to shorten diagnostic delay involved: (a) educating PCPs and other non-neurologist "gatekeeper" providers, (b) improving access to specialist neurology care, and (c) developing a reliable diagnostic test for ALS. DISCUSSION Self-reported factors that increase ALS diagnostic delay among PCPs primarily comprise gaps in clinical knowledge and skills required to detect key symptoms and signs, and suboptimal referral access to a neurology/NM provider. These areas represent important opportunities for targeted improvement efforts.
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16
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Kim MY, Choi SJ, Kim JH, Leem CS, Kang YA. [Intention to Delegate Clinical Practice of Medical Specialists in Accordance with the Enactment of the Scope of Practice for Advanced Practice Nurses]. J Korean Acad Nurs 2023; 53:39-54. [PMID: 36898684 DOI: 10.4040/jkan.22098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/15/2022] [Accepted: 02/08/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE This study aimed to investigate the nationwide intention to delegate clinical practice of medical specialists in accordance with the enactment of the scope of practice for advanced practice nurses (APNs). METHODS Data were collected from October to December 2021 using Google Surveys. In total, 147 medical specialists from 12 provinces responded to the survey. The survey questionnaire was categorized into four legislative draft duties, according to the scope of practice (a total of 41 tasks): Twenty-nine tasks on treatments, injects, etc., performed under the guidance of a physician and other activities necessary for medical treatment (treatment domain); two tasks on collaboration and coordination; six tasks on education, counseling, and quality improvement; four regarding other necessary tasks. Participants were asked whether they were willing to delegate the tasks to APN. RESULTS The intention to delegate tasks to APN was higher for non-invasive tasks such as blood sampling (97.3%) or simple dressing (96.6%). Invasive tasks such as endotracheal tube insertion (10.2%), sampling: bone marrow biopsy & aspiration (23.8%) showed low intention to delegate in the treatment domain. Participants who were older, male, and had more work careers with APN, showed a higher intention to delegate tasks. CONCLUSION To prevent confusion in the clinical setting, a clear agreement on the scope of APN practice as APN delegated by physicians should be established. Based on this study, legal practices that APN can perform legally should be established.
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Affiliation(s)
- Min Young Kim
- College of Nursing, Health and Nursing Research Institute, Jeju National University, Jeju, Korea
| | - Su Jung Choi
- Graduate School of Clinical Nursing Science, Sungkyunkwan University, Seoul, Korea.
| | - Jeong Hye Kim
- Department of Clinical Nursing, University of Ulsan, Seoul, Korea
| | - Cho Sun Leem
- Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Ah Kang
- Department of Nursing, Asan Medical Center, Seoul, Korea
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17
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Hollenbeck BK, Kaufman SR, Oerline M, Modi PK, Caram ME, Shahinian VB, Ellimoottil C. Effects of Advanced Practice Providers on Single-specialty Surgical Practice. Ann Surg 2023; 277:e40-e45. [PMID: 33914476 PMCID: PMC8989058 DOI: 10.1097/sla.0000000000004846] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effects of adding advanced practice providers to surgical practices on surgical complications, readmissions, mortality, episode spending, length of stay, and access to care. SUMMARY BACKGROUND DATA There has been substantial growth in the number of nurse practitioners and physician assistants (ie, advanced practice providers) in the United States. The extent to which advanced practice providers have been integrated into surgical practice, and their impact on surgical outcomes and access is unclear. METHODS Using a 20% sample of national Medicare claims, we performed a retrospective cohort study of fee-for-service beneficiaries undergoing one of 4 major procedures (coronary artery bypass graft, colectomy, major joint replacement, and cystectomy) between 2010 and 2016. We limited our study population for each procedure to patients treated by single-specialty surgical groups to ensure that the advanced practice providers have direct interactions with its surgeons and patients. All outcomes were measured at the practice level for the year before and the year after the addition of the first advanced practice provider. Outcomes included: complications, readmission, mortality, episode payments, length of stay. Models were adjusted for age, race, sex, comorbidity, socioeconomic class and procedure type. Secondary outcome: practice-level office visits by surgical group type. RESULTS The number of advanced practice providers increased by 13%, from 6713 to 7596 between 2010 and 2016. The largest relative increases occurred in general (46.9%) and urologic (27.6%) surgical practices. The year after an advanced practice provider was added to a surgical practice, the odds of complications were 17% and 16% lower at 30- and 90-days postprocedure, respectively. Additionally, 90-day readmissions were 18% less likely and length of stay was 0.33 days shorter (a 7.1% reduction). Average 30-day and90-day episode spending was $1294.73 and $1427.76 lower, respectively ( P < 0.001). General surgical, orthopedic, and urology practices realized increases of 49.0 (95% CI 13.5-84.5), 112.0 (95% CI 83.0-140.5), and 205.0 (95% CI 117.5-292.0) in-office visits per surgeon, respectively. CONCLUSIONS The addition of advanced practice providers to single-specialty surgical groups is associated with improvements in surgical outcomes and access. Future work should clarify the mechanisms by which advanced practice providers within surgical practices contribute to health outcomes to identify best practices for deployment.
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Affiliation(s)
| | | | - Mary Oerline
- Departments of Urology, University of Michigan, Ann Arbor
| | - Parth K. Modi
- Departments of Urology, University of Michigan, Ann Arbor
| | | | - Vahakn B. Shahinian
- Departments of Urology, University of Michigan, Ann Arbor
- Departments of Medicine, University of Michigan, Ann Arbor
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18
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Bruch JD, Foot C, Singh Y, Song Z, Polsky D, Zhu JM. Workforce Composition In Private Equity-Acquired Versus Non-Private Equity-Acquired Physician Practices. Health Aff (Millwood) 2023; 42:121-129. [PMID: 36623222 DOI: 10.1377/hlthaff.2022.00308] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite growth in private equity (PE) acquisitions of physician practices in the US, little is known about how changes in ownership influence workforce composition. Using clinician-level data linked to practice acquisition information, we estimated changes in clinician workforce composition in PE-acquired practice sites relative to non-PE-acquired independent practice sites for dermatology, ophthalmology, and gastroenterology specialties. We calculated a clinician replacement ratio (cumulative number of entering clinicians during 2014-19 divided by the cumulative number of exiting clinicians) across 213 PE-acquired practices and 995 matched non-PE-acquired practices. Using a difference-in-differences approach, we also examined practice-level changes in yearly clinician counts at PE-acquired practices before and after acquisition compared with non-PE-acquired controls. In aggregate and across the study period, the clinician replacement ratio was higher for PE-acquired practices compared with non-PE-acquired controls (1.75 versus 1.37), as well as within each specialty and clinician type (physician versus advanced practice provider). Relative to non-PE-acquired control practices, we also found significant yearly increases in the number of advanced practice providers at PE-acquired practices after acquisition. Taken together, these findings suggest differential changes in workforce composition at PE-acquired practices, especially a shift toward advanced practice providers for care delivery.
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Affiliation(s)
| | - Canyon Foot
- Canyon Foot, Oregon Health & Science University, Portland, Oregon
| | | | - Zirui Song
- Zirui Song, Harvard University, Boston, Massachusetts
| | | | - Jane M Zhu
- Jane M. Zhu , Oregon Health & Science University
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Virarkar M, Coleman JA, Siddiqui ZA, Leal VB, McClinton AE, Steele JR, Yang W, Bhosale PR, Klekers AR. Engaging nurse practitioners and physician assistants to improve patient care and drive productivity in a radiology consult practice at a comprehensive cancer center. J Am Assoc Nurse Pract 2022; 34:941-947. [PMID: 35796110 DOI: 10.1097/jxx.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The demand for health care in the United States is increasing because of an aging population and an increase in the number of individuals insured. This has led to requests to revamp the primary care infrastructure fundamentally. LOCAL PROBLEM The optimal use of nurse practitioners (NPs) and physician assistants (PAs) is still a subject of debate, but recently, it was reported that for many medical conditions, NP and PA-managed care outcomes are consistent with physician-managed care outcomes. METHODS Radiologists' productivity was measured according to relative value units (RVUs)/shift and professional billing changes. Patient care metrics measured were prescribed protocol to patient appointment lead time and number of same-day prescribed imaging protocol changes. INTERVENTIONS The focus was on radiologists' productivity and patient care for three months before and three months after integrating NP and PA into our abdominal radiology consult service. RESULTS We observed significant increases in the mean RVUs/shift (15.2 ± 0.9 vs. 6.2 ± 1.8; p = .02), studies read per shift (10.1 ± 0.5 vs. 4.4 ± 1.5; p = .003), revenue per shift hour ($756.20 ± 55.40 vs. $335.40 ± 32.60; p = .007), and protocol prescription to patient appointment lead time (39.3 ± 6.7 days vs. 16.3 ± 2.9 days; p = .005) and saw significant decreases in the mean prescribed CT (19.3 ± 0.6 vs. 3.3 ± 0.6; p = .001) and MRI (11.7 ± 0.6 vs. 8.30 ± 0.12; p = .011) same day protocol changes in NP and PA integrated workflow. CONCLUSIONS These findings suggest that NP and PA can be effectively integrated into the abdominal radiology consult service, increasing radiologists' productivity and enhancing clinical care.
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Affiliation(s)
- Mayur Virarkar
- Division of Abdominal and General Body Imaging, University of Florida College of Medicine, Jacksonville, Florida
| | - Joseph A Coleman
- College of Natural Sciences, Biology Major, University of Houston, Houston, Texas
| | - Zeeshan A Siddiqui
- Department of Ambulatory Operation & Access, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Viola B Leal
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Angel E McClinton
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph R Steele
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wei Yang
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Priya R Bhosale
- Department of Abdominal Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert R Klekers
- Department of Abdominal Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Virarkar M, Coleman JA, Siddiqui ZA, Leal VB, McClinton AE, Steele JR, Yang W, Bhosale P, Klekers AR. PAs and NPs improve patient care and productivity in a radiology consult practice. JAAPA 2022; 35:46-51. [PMID: 35762956 DOI: 10.1097/01.jaa.0000832596.64788.f1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effects on efficiency and patient care of the addition of physician assistants (PAs) and NPs to the abdominal radiology consult service. METHODS We obtained radiologist productivity and patient care metrics for 3 months before and 3 months after the integration of PAs and NPs into our consult service. RESULTS Integrating PAs and NPs into the workflow led to a significant increase in mean RVUs/shift (15.2 ± 0.9 versus 6.2 ± 1.8; P = .02), number of studies read per shift (10.1 ± 0.5 versus 4.4 ± 1.5; P = .003), revenue per shift hour ($756.20 ± $55.40 versus $335.40 ± $132.60; P = .007), protocol prescription to patient appointment lead time (39.3 ± 6.7 versus 16.3 ± 2.9 days; P = .005), and significant decreases in mean CT (19.3% ± 0.6 versus 3.3% ± 0.6; P = .001) and MRI (11.7% ± 0.6 versus 8.3% ± 0.12; P = .011) same-day protocol changes as patient appointments. CONCLUSIONS PAs and NPs can be effectively integrated into abdominal radiology consult service, increasing the productivity of radiologists, and enhancing clinical care.
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Affiliation(s)
- Mayur Virarkar
- Mayur Virarkar is an assistant professor in the Division of Abdominal and General Body Imaging at the University of Florida College of Medicine in Jacksonville, Fla. Joseph A. Coleman is a student at the University of Houston in Houston, Tex. At the University of Texas' MD Anderson Cancer Center in Houston, Zeeshan A. Siddiqui is a project director in the Department of Ambulatory Operation and Access, Viola B. Leal is a program manager, Angel E. McClinton practices in surgical oncology, Joseph R. Steele is an interventional radiologist, Wei Yang is a professor and chair of the Department of Diagnostic Radiology, Priya Bhosale is a professor in the departments of diagnostic radiology and abdominal imaging, and Albert R. Klekers is an assistant professor in the Department of Abdominal Radiology. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Letter to the Editor. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Barnes H, Martsolf GR, McHugh MD, Richards MR. Vertical Integration and Physician Practice Labor Composition. Med Care Res Rev 2022; 79:46-57. [PMID: 33185148 PMCID: PMC8340031 DOI: 10.1177/1077558720972596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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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23
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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] [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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Creating an operational definition for prolonged postoperative opioid use through the use of concept analysis. Appl Nurs Res 2021; 62:151506. [PMID: 34815002 DOI: 10.1016/j.apnr.2021.151506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/24/2022]
Abstract
AIM To develop an evidence-based operational definition for Prolonged Postoperative Opioid Use (PPOU). BACKGROUND In the United States, opioids are a mainstay of postoperative pain management, and are prescribed to over 90% of patients following surgery. Recent literature has highlighted the risk for prolonged postoperative opioid use (PPOU) after many surgical procedures. However, reported rates of PPOU vary greatly across studies, due in part to inconsistent operational definitions. Recent literature identified 29 distinct definitions for PPOU, which resulted in incidence ranging from 0.01% to 14.7% when applied to the same cohort of opioid naïve patients. METHODS We followed the eight-step method described by Walker & Avant, using an iterative literature search process with the following databases: PubMed, CINAHL, Google Scholar. English-language peer-reviewed publications through August 2020 were included in the analysis. RESULTS The four defining attributes of PPOU are (1) use of opioids greater than 90 days following surgery, (2) treatment of postoperative (non-cancer) pain, (3) in opioid-naïve patients, (4) with legal prescription use. We identified four antecedents and four consequences to PPOU. CONCLUSION The definition of PPOU in current literature varies greatly and has had significant impact on the interpretation and reliability of research findings. We propose the following working definition: PPOU is the legal prescription use of any opioid for greater than 90 days following surgery, for the purposes of treating post-operative pain, by a patient who opioid naïve in the year prior to surgery.
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Advanced practice providers in the infectious disease workforce: A nationwide utilization survey. JOURNAL OF INTERPROFESSIONAL EDUCATION & PRACTICE 2021; 24:100448. [PMID: 36567810 PMCID: PMC9765300 DOI: 10.1016/j.xjep.2021.100448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022]
Abstract
Background Shortages of infectious disease (ID) physicians is an identified workforce problem. The COVID-19 pandemic has exacerbated this care gap, leaving many communities without access to an ID physician. More advanced practice providers (APPs), specifically nurse practitioners and physician assistants, work as healthcare extenders, yet are not well described in ID. Purpose Evaluate collaboration between ID physicians and APPs, and potential barriers to utilization of APPs. Methods Anonymous and voluntary surveys; one for physicians, another for APPs. We collected experience, practice setting, familiarity regarding APPs in ID, use of APPs, and perceived barriers/concerns for utilization of APPs. Discussion Nationwide, 218 ID physicians and 93 APPs in ID responded. 71% (155) of ID physicians use APPs. Of APPs, 53% (49) had > 5 years ID experience. Responses highlighted opportunities for dedicated ID education, collaboration, and clarification of practice scope. Conclusion APPs are an experienced group who provide ID care, working alongside physicians to meet ID workforce needs.
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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] [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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Yalamanchi P, Blythe M, Gidley KS, Blythe WR, Waguespack RW, Brenner MJ. The Evolving Role of Advanced Practice Providers in Otolaryngology: Improving Patient Access and Patient Satisfaction. Otolaryngol Head Neck Surg 2021; 166:6-9. [PMID: 34154448 DOI: 10.1177/01945998211020314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aging US population requires an increasing volume of otolaryngology-head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Kristi S Gidley
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Richard W Waguespack
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Differences in the number of services provided by nurse practitioners and physicians during primary care visits. Nurs Outlook 2021; 69:886-891. [PMID: 34092371 DOI: 10.1016/j.outlook.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/31/2021] [Accepted: 04/10/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Due to differential training, nurse practitioners (NPs) and physicians may provide different quantities of services to patients. PURPOSE To assess differences in the number of laboratory, imagining, and procedural services provided by primary care NPs and physicians. METHODS Secondary analysis of 2012-2016 National Ambulatory Medical Care Survey (NAMCS), containing 308 NP-only and 73,099 physician-only patient visits, using multivariable regression and propensity score techniques. FINDINGS On average, primary care visits with NPs versus physicians were associated with 0.521 fewer laboratory (95% CI -0.849, -0.192), and 0.078 fewer imaging services (95% CI -0.103,-0.052). Visits for routine and preventive care with NPs versus physicians were associated with 1.345 fewer laboratory (95% CI -2.037,-0.654), and 0.086 fewer imaging services (95% CI -0.118,-0.054) on average. Primary care visits for new problems with NPs versus physicians were associated with 0.051 fewer imaging services (95% CI -0.094,-0.007) on average. DISCUSSION NPs provide fewer laboratory and imaging services than physicians during primary care visits.
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Abstract
OBJECTIVE Employment analyses demonstrate that physician assistants (PAs) exhibit role flexibility in US medicine. The next step in understanding this labor-shifting observation is to know at what career stage it first occurs. METHODS Using matriculate data linked to the American Academy of PAs (AAPA) census survey data, a longitudinal analysis of seven graduate cohorts revealed that one-third of PAs changed specialty roles at least once during their first decade of employment. RESULTS From this series, it appears that new PAs spend about 3.4 years in their first job, on average, before they decide to move to another medical or surgical field. In examining PAs who changed their clinical role during this time period, 28% shifted from primary care to another medical or specialty role. Overall, the PA career movement to nonprimary care specialties increased substantially. CONCLUSIONS These findings support observations that PAs provide an adaptive role in a dynamic and changing medical workforce.
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Affiliation(s)
- Alicia K Quella
- Alicia K. Quella is a clinical associate professor, and chair/program director of the PA program at Augsburg University in Minneapolis, Minn. Roderick S. Hooker is an adjunct professor of health policy at Northern Arizona University in Phoenix. John M. Zobitz is a professor of mathematics, statistics, and computer science at Augsburg University. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Bernasko N, Clarke K. Why Is There Low Utilization of Biosimilars in Inflammatory Bowel Disease Patients by Gastroenterology Advanced Practice Providers? CROHN'S & COLITIS 360 2021; 3:otab004. [PMID: 36777276 PMCID: PMC9802381 DOI: 10.1093/crocol/otab004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
Aim To assess knowledge, practice patterns and attitudes toward the use of biosimilars by Advanced Practice Providers (APPs) treating patients with inflammatory bowel disease (IBD). Background APPs provide care in a variety of healthcare settings including medical specialties. In Gastroenterology, they are an integral part of providing care to a complex group of patients with IBD. There has been an increase in options of medical therapies for treating IBD. These include small molecules, biologics, and biosimilars. Adoption of biosimilars for treatment of IBD patients by gastroenterologists in the United States compared to Europe has been slow for several reasons. There is lack of data on their use by APPs who provide frontline IBD clinical care in the United States. Methods Questionnaire-based survey of APPs attending Gastroenterology conferences with a focus on IBD. Results APPs in gastroenterology do not routinely consider the use of biosimilars in their practice. Conclusions There is low utilization of biosimilars in treating IBD patients by APPs. In addition, there are significant concerns about risk of side effects as well as perceived lack of APP targeted educational resources.
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Affiliation(s)
- Nana Bernasko
- Department of Medicine, Penn State Hershey Medical Center, Division of Gastroenterology and Hepatology, Hershey, Pennsylvania, USA
| | - Kofi Clarke
- Department of Medicine, Penn State Hershey Medical Center, Division of Gastroenterology and Hepatology, Hershey, Pennsylvania, USA,Address correspondence to: Kofi Clarke, MD, FACP, FRCP, AGAF, Penn State Hershey Medical Center, Division of Gastroenterology and Hepatology, 500 University Drive, Mail Code HU 33, Hershey, PA 17033, USA ()
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Kesten KS, Beebe SL. Competency frameworks for nurse practitioner residency and fellowship programs: Comparison, analysis, and recommendations. J Am Assoc Nurse Pract 2021; 34:160-168. [PMID: 33767119 DOI: 10.1097/jxx.0000000000000591] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Nurse practitioner (NP) education has followed the pattern of other health professions in recent years to place an emphasis on competency-based education. In recent years, postgraduate NP residency/fellowship programs to achieve competence and successful transition to practice have emerged and flourished. Currently, there is no standard competency framework in use for NP residency/fellowship programs in the United States, despite numerous published frameworks available. This article aimed to provide a comprehensive analysis of competency frameworks for NP education and to summarize and compare the competency frameworks used in NP education and residency/fellowship programs. Recommendations were sought for standardization of these competencies to create consistent evaluation and outcome measurements. Seven competency frameworks used across NP education and residency/fellowship programs were reviewed and compared in table format. Commonalities, differences, and themes were extracted from this comparison. There were more similarities than differences between the competency frameworks; however, common themes emerged as the emphasis on patient-centered, evidence-based practice, systems-based and quality improvement, and interprofessional practice and teamwork. The American Association of Colleges of Nursing Common Advanced Practice Registered Nurse Doctoral-Level Competencies, published in 2017, provided the most current, inclusive, comprehensive, and complete set of competencies for NPs at the time of graduation; however, they have not defined a progression indicator for postgraduate NP competency evaluation. This review of the competencies emphasizes (a) the need for consistent and consensus-based standards and (b) areas that NP education and residency/fellowship programs can strengthen to assess their ability to describe observable, measurable competencies. Instruments to evaluate competencies are recommended.
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Affiliation(s)
- Karen S Kesten
- Acute and Chronic Care Community, School of Nursing, The George Washington University, Washington, District of Columbia
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Patel RA, Torabi SJ, Kasle DA, Pivirotto A, Manes RP. Role and Growth of Independent Medicare-Billing Otolaryngologic Advanced Practice Providers. Otolaryngol Head Neck Surg 2021; 165:809-815. [PMID: 33687283 DOI: 10.1177/0194599821994820] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the role and growth of independently billing otolaryngology (ORL) advanced practice providers (APPs) within a Medicare population. STUDY DESIGN Retrospective cross-sectional study. SETTING Medicare Provider Utilization and Payment Data: Physician and Other Supplier Data Files, 2012-2017. METHODS This retrospective review included data and analysis of independent Medicare-billing ORL APPs. Total sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique Current Procedural Terminology (CPT) codes used, along with geographic and sex distributions. RESULTS There has been near-linear growth in number of ORL APPs (13.7% to 18.4% growth per year), with a 115.4% growth from 2012 to 2017. Similarly, total Medicare-allowed reimbursement (2012: $15,568,850; 2017: $35,548,446.8), total number of services performed (2012: 313,676; 2017: 693,693.7), and total number of Medicare fee-for-service (FFS) patients (2012: 108,667; 2017: 238,506) increased. Medians of per APP number of unique CPT codes used, Medicare-allowed reimbursement, number of services performed, and number of Medicare FFS patients have remained constant. There were consistently more female APPs than male APPs (female APP proportion range: 71.3%-76.7%). Compared to ORL physicians, there was a significantly greater proportion of APPs practicing in a rural setting as opposed to urban settings (2017: APP proportion 13.6% vs ORL proportion 8.4%; P < .001). CONCLUSION Although their scope of practice has remained constant, independently billing ORL APPs are rapidly increasing in number, which has led to increased Medicare reimbursements, services, and patients. ORL APPs tend to be female and are used more heavily in regions with fewer ORL physicians.
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Affiliation(s)
- Rahul A Patel
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA.,Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sina J Torabi
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David A Kasle
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Allison Pivirotto
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
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Specialty practice: Successes and challenges. J Am Assoc Nurse Pract 2021; 33:181-183. [PMID: 33690257 DOI: 10.1097/jxx.0000000000000594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
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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] [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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Barnes H, Faraz Covelli A, Rubright JD. Development of the novice nurse practitioner role transition scale: An exploratory factor analysis. J Am Assoc Nurse Pract 2021; 34:79-88. [PMID: 33625161 PMCID: PMC8715992 DOI: 10.1097/jxx.0000000000000566] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Novice nurse practitioner role transition (NNPRT) can be described as stressful and turbulent, leading to decreased job satisfaction and increased intent to leave. No published instrument exists to measure NNPRT. Thus, researchers, educators, and administrators are limited in their ability to measure the concept and therefore understand the factors that lead to a successful, or unsuccessful, role transition experience. An instrument with evidence of validity and reliability is needed to conduct large-scale and systematic examinations of NNPRT. PURPOSE The purpose of this study was to develop and examine the initial factor structure of a novel instrument that measures NNPRT. METHODS Initial item development was guided by concept analysis, literature review, and qualitative data. Face and content validity were established from expert review. Using pilot data from 89 novice nurse practitioners (NPs), an exploratory factor analysis (EFA) was conducted to examine the instrument's internal factor structure. RESULTS The NNPRT Scale includes 40 items that measure an individual's perception of their role transition experience. The EFA revealed a five-factor structure: organizational alignment, mentorship, sense of purpose, perceived competence and self-confidence, and compensation. IMPLICATIONS FOR PRACTICE In an evolving health care system, provider well-being is at the center of workforce, educational, and organizational conversations. Understanding how to optimize the workforce and prepare NPs for health care delivery is increasingly important. The NNPRT Scale will allow for large-scale examinations of the factors that influence NP role transition, as well as assess interventions to prepare and support novice NPs' transitions.
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Affiliation(s)
- Hilary Barnes
- School of Nursing, University of Delaware, Newark, Delaware
| | - Asefeh Faraz Covelli
- School of Nursing, The George Washington University, Washington, District of Columbia
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Jimenez EY, Kelley K, Schofield M, Brommage D, Steiber A, Abram JK, Kramer H. Medical Nutrition Therapy Access in CKD: A Cross-sectional Survey of Patients and Providers. Kidney Med 2021; 3:31-41.e1. [PMID: 33604538 PMCID: PMC7873758 DOI: 10.1016/j.xkme.2020.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
RATIONALE & OBJECTIVE Nutrition management can slow the progression of chronic kidney disease (CKD) and help manage complications of CKD, but few individuals with CKD receive medical nutrition therapy before initiating dialysis. This study aimed to identify knowledge, attitudes, experiences, and practices regarding medical nutrition therapy and barriers and facilitators to medical nutrition therapy access for individuals with CKD stages G1-G5 from the perspective of patients and providers. STUDY DESIGN Cross-sectional study composed of anonymous surveys. SETTING & POPULATION Adults with CKD stages G1-G5 and medical providers and registered dietitian nutritionists who regularly see patients with CKD stages G1-G5 were recruited by email using National Kidney Foundation and Academy of Nutrition and Dietetics databases and through the National Kidney Foundation 2019 Spring Clinical Meetings mobile app. ANALYTICAL APPROACH Descriptive analyses and Fisher exact tests were conducted with Stata SE 16. RESULTS Respondents included 348 patients, 66 registered dietitian nutritionists, and 30 medical providers. In general, patients and providers had positive perceptions of medical nutrition therapy and its potential to slow CKD progression and manage complications, and most patients reported interest in a medical nutrition therapy referral. However, there were feasibility concerns related to cost to the patient, lack of insurance coverage, and lack of renal registered dietitian nutritionists. There was low awareness of Medicare no-cost share coverage for medical nutrition therapy across patients and providers. About half the practices did not bill for medical nutrition therapy and those that did reported issues with being paid and low reimbursement rates. LIMITATIONS Results may not be generalizable due to the small number of respondents and the potential for self-selection, nonresponse, and social desirability bias. CONCLUSIONS Many patients with CKD stages G1-G5 are interested in medical nutrition therapy and confident that it can help with disease management, but there are feasibility concerns related to cost to the patient, insurance coverage, and reimbursement. There are significant opportunities to design and test interventions to facilitate medical nutrition therapy access for patients with CKD stages G1-G5.
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Affiliation(s)
- Elizabeth Yakes Jimenez
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- College of Population Health, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Kathryn Kelley
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Marsha Schofield
- Governance and Nutrition Services Coverage, Academy of Nutrition and Dietetics, Chicago, IL
| | | | - Alison Steiber
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Jenica K. Abram
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Holly Kramer
- Division of Nephrology and Hypertension, Department of Public Health Sciences and Medicine, Loyola University Medical Center, Maywood, IL
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Gigli KH, Kahn J, Martsolf G. Availability of Acute Care Pediatric Nurse Practitioner Education in the United States: A Challenge to Growing the Workforce. J Pediatr Health Care 2020; 34:481-489. [PMID: 32173222 PMCID: PMC7483205 DOI: 10.1016/j.pedhc.2020.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 11/15/2022]
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Redeployment of Orthopaedic Advanced Practice Providers at Academic Medical Centers During the COVID-19 Pandemic. Orthop Nurs 2020; 39:215-217. [PMID: 32665477 PMCID: PMC7377649 DOI: 10.1097/nor.0000000000000689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The novel coronavirus (SARS-CoV-2) represents a rapidly evolving pandemic. Health systems are scrambling to mobilize and redeploy their medical staff in the fight against COVID-19. Orthopaedic nurse practitioners/physician assistants should be part of any redeployment strategy to address unmet needs during these unprecedented times. This article discusses redeployment considerations and strategies that utilize these providers appropriately while mitigating risks.
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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] [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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Measurement of nonbillable service value activities by nurse practitioners, physician assistants, and clinical nurse specialists in ambulatory specialty care. J Am Assoc Nurse Pract 2020; 33:211-219. [PMID: 32618735 DOI: 10.1097/jxx.0000000000000439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Revenue-generating health care activities, generally accepted as a measure of productivity, do not account for the full range of health care activities that enhance patient care. PURPOSE We analyzed the quantity, duration, and type of "service value activities" performed by nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), which are nonbillable service activities that contribute to billable service provision, quality of care, and value of care. METHODS Data were obtained from ambulatory specialties at one health care institution over a 13-month period. First, descriptive statistics were calculated by time-based code for each category of provider (medical, surgical, transplant, hematology/oncology, and anesthesia). Then qualitative comments were analyzed for frequency of key words. RESULTS Each provider spent an estimated average of between 3.7 and 36.5 hours per month on service value activities, with the greatest number of these activities related to orders, chart review, and documentation. IMPLICATIONS FOR PRACTICE More thorough exploration of the quantity and type of service value activities performed may lead to a better understanding of the role and contribution of NPs, PAs, CNSs, and other health care professionals to patient care.
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Carranza AN, Munoz PJ, Nash AJ. Comparing quality of care in medical specialties between nurse practitioners and physicians. J Am Assoc Nurse Pract 2020; 33:184-193. [PMID: 32384361 DOI: 10.1097/jxx.0000000000000394] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings. OBJECTIVE This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction. DATA SOURCES The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review. CONCLUSIONS Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction. IMPLICATIONS FOR PRACTICE Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.
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Affiliation(s)
- Ashley N Carranza
- The University of Texas Health Science Center (UTHealth), Cizik School of Nursing (CSON), Houston, Texas
| | - Pamela J Munoz
- The University of Texas Health Science Center (UTHealth), Cizik School of Nursing (CSON), Houston, Texas
| | - Angela J Nash
- Department of Graduate Studies, UTHealth, CSON, Houston, Texas
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Winter SG, Duderstadt K, Chan GK, Spetz J, Stephan LM, Matsuda E, Chapman SA. Service Value Activities by Nurse Practitioners in Ambulatory Specialty Care. Policy Polit Nurs Pract 2020; 21:95-104. [PMID: 32486957 DOI: 10.1177/1527154420927689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The increase in nurse practitioners (NPs) in ambulatory medical and surgical specialty settings has prompted inquiry into their role and contribution to patient care. We explored the role and contribution of NPs in ambulatory specialty care through their activities outside of direct care and billable visits (referred to as service value activities), and how NPs perceive these activities enhance quality and efficiency of care, for both patients and the health care institution. This qualitative thematic analysis examined interviews from 16 NPs at a large academic medical center about their role and contribution to patient care quality and departmental efficiency beyond billable visits. Five categories of NP contribution were identified: promoting patient care continuity, promoting departmental continuity, promoting institutional historical and insider knowledge, addressing time-sensitive issues, and participating in leadership and quality improvement activities. As the role of NPs in specialty care grows and health care systems emphasize quality of care, it is appropriate to explore the quality- and efficiency-enhancing activities NPs perform in specialty care beyond direct patient care.
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Affiliation(s)
- Shira G Winter
- VA Palo Alto Health Care System, Center for Innovation to Implementation, Menlo Park, California
- Center for Health Policy, Primary Care and Outcomes Research, Stanford University School of Medicine
| | - Karen Duderstadt
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco
| | - Garrett K Chan
- Department of Physiological Nursing, University of California, San Francisco
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Linda M Stephan
- Department of Family Health Care Nursing, University of California, San Francisco
| | - Erin Matsuda
- Benioff Children's Hospitals, University of California, San Francisco
| | - Susan A Chapman
- Department of Social and Behavioral Sciences, University of California, San Francisco
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Facilitators, barriers, benefits, and funding to implement postgraduate nurse practitioner residency/fellowship programs. J Am Assoc Nurse Pract 2020; 33:611-617. [PMID: 32282566 DOI: 10.1097/jxx.0000000000000412] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND A current trend to address the increasing numbers of new graduate nurse practitioners (NPs) and the expanding scope of practice of NPs is the emergence of employer-based postgraduate NP residency/fellowship programs. PURPOSE The purpose of this study was to conduct a comprehensive examination of postgraduate NP residency/fellowship programs in the United States, to gain an understanding of the facilitators, barriers, benefits, and funding of these programs, from the perspective of the program directors. METHODS This exploratory study used a quantitative design to conduct an online survey, developed by the researchers, of program directors of postgraduate NP residency/fellowship programs. Descriptive statistics were generated for continuous variables: the mean, SD, and minimum, and maximum values, and for categorical variables, frequency and percentage were reported. RESULTS More than 90% of program directors indicated that NP recruitment and retention were benefits to organizations implementing NP residency/fellowship programs. Decision makers in organizations support postgraduate NP residency/fellowship programs and few barriers exist to implement programs. More than 84% indicated that physician and administrative support were facilitators to program implementation. Less than 50% of program directors identified barriers to implementation. Less than half of programs received funding sources for program implementation. IMPLICATIONS FOR PRACTICE This study provides data and insight into the emerging industry of postgraduate NP residency/training programs and informs regulators, educators, and employers about how to maximize the facilitators, reduce and decrease barriers, identify sources of funding, and appreciate the benefits of implementing programs.
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A Call to Action - Nursing Must Do More to Reduce Lower Urinary Tract Symptoms. Int J Nurs Stud 2020; 107:103577. [PMID: 32339932 DOI: 10.1016/j.ijnurstu.2020.103577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/26/2022]
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Ganguli I, Shi Z, Orav EJ, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016. Ann Intern Med 2020; 172:240-247. [PMID: 32016285 DOI: 10.7326/m19-1834] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. OBJECTIVE To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. DESIGN Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. SETTING National, population-based. PARTICIPANTS Adult health plan members aged 18 to 64 years. MEASUREMENTS PCP visit rates per 100 member-years. RESULTS In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). LIMITATION Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions. CONCLUSION Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Zhuo Shi
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - E John Orav
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York City, New York (A.R.)
| | - Kristin N Ray
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (K.N.R.)
| | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
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46
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Bohnhoff JC, Taormina JM, Ferrante L, Wolfson D, Ray KN. Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral. Pediatrics 2019; 144:peds.2019-0545. [PMID: 31704770 DOI: 10.1542/peds.2019-0545] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Incomplete subspecialty referrals, whether unscheduled or unattended, represent unmet patient needs and an opportunity to improve patient safety and experiences. Our objectives were to describe the rates of appointment scheduling and visit attendance after pediatric subspecialty referral and to examine patient and systems factors associated with scheduled referrals and attended appointments. METHODS We conducted a retrospective review of referrals within a network of 52 primary and urgent care sites from November 2016 to October 2017. We included referrals for children ≤17 years old referred to medical or surgical subspecialists. We examined patient and health systems factors associated with (1) appointment scheduling and (2) visit attendance. RESULTS Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days. In adjusted analyses, referral to surgical subspecialists was associated with an increased likelihood of appointment scheduling but a decreased likelihood of visit attendance. Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8-14 days 0.48; 95% confidence interval 0.37-0.61). Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income. CONCLUSIONS Patient and system factors were associated with variation in appointment scheduling and visit attendance. Decreased interval to appointment was significantly associated with visit attendance. These factors represent targets for interventions to improve referral completion.
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Affiliation(s)
- James C Bohnhoff
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania;
| | - Jill M Taormina
- Children's Community Pediatrics, Pittsburgh, Pennsylvania; and
| | | | - David Wolfson
- Children's Community Pediatrics, Pittsburgh, Pennsylvania; and
| | - Kristin N Ray
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.,Children's Community Pediatrics, Pittsburgh, Pennsylvania; and.,Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
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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] [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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van den Brink GTWJ, Kouwen AJ, Hooker RS, Vermeulen H, Laurant MGH. An activity analysis of Dutch hospital-based physician assistants and nurse practitioners. HUMAN RESOURCES FOR HEALTH 2019; 17:78. [PMID: 31665010 PMCID: PMC6819603 DOI: 10.1186/s12960-019-0423-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management. STUDY DESIGN A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated. METHODS The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system. FINDINGS In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care. CONCLUSIONS NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.
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Affiliation(s)
- G T W J van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Master Programs, HAN University of Applied Sciences, PO box 6960, 6503 GL, Nijmegen, The Netherlands.
| | - A J Kouwen
- Radboud University Medical Center, PVI, Nijmegen, The Netherlands
| | - R S Hooker
- Health Policy Analyst, Ridgefield, WA, United States of America
| | - H Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M G H Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Institute of Nursing Studies, Nijmegen, The Netherlands
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O'Reilly-Jacob M, Perloff J, Buerhaus P. Low-Value Back Imaging in the Care of Medicare Beneficiaries: A Comparison of Nurse Practitioners and Physician Assistants. Med Care Res Rev 2019; 78:197-207. [PMID: 31549583 DOI: 10.1177/1077558719877796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs (N = 234) order low-value back images significantly less than PAs (N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points (p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.
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O'Rourke P, Tseng E, Chacko K, Shalaby M, Cioletti A, Wright S. A National Survey of Internal Medicine Primary Care Residency Program Directors. J Gen Intern Med 2019; 34:1207-1212. [PMID: 30963438 PMCID: PMC6614222 DOI: 10.1007/s11606-019-04984-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/11/2018] [Accepted: 03/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.
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Affiliation(s)
- Paul O'Rourke
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Eva Tseng
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Chacko
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc Shalaby
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Cioletti
- Division of Primary Care and Value-Based Health, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Scott Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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