Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE

To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals.

DATA SOURCES/STUDY SETTING

The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs.

STUDY DESIGN

Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design.

DATA COLLECTION/EXTRACTION METHODS

Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items.

PRINCIPAL FINDINGS

After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states.

CONCLUSIONS

Findings do not support a quality-scope of practice relationship.

Hearing aids for nursing home residents: Current policy and future needs

Hearing aids are crucial for people with hearing loss, especially dementia patients in nursing homes. However, the actual use of hearing aids in this population is very low. A major barrier to use is the cost. This paper examines the issue in terms of current financial coverage available through federal and state systems as well as private insurance. We discuss the applicability of the Americans with Disabilities Act (ADA) and other federal laws to this problem. There is a need for future policy development to improve both the quality of hearing aids and the financial mechanisms that will allow nursing home residents to use them. Plans to move the policy agenda forward are suggested.

Policy initiatives to promote healthy aging

An overwhelming array of policies and programs can be used to help older people (and future older people) maintain healthy lifestyles. How can clinicians help ensure that their patients take advantage of these opportunities? How can these broad-scope policies, educational and information initiatives, and direct service programs be turned into tools to help older people maximize health and independence? First, physicians do not need to do it all themselves. They need to know where to send their patients. For example, case managers in local aging service organizations and social workers, nurses, and discharge planners in hospitals can help connect elderly patients to appropriate benefits and services. Physicians play a critical role in creating a bridge between patients and the array of programs and information that can help them change their individual patterns of behavior. A serious lack of integration exists between what is known about healthy behaviors and lifestyles and what is really happening and available to older people today. From the earlier articles in this issue we know that much can be done to prevent many types of age-related disease and disability. This article provides examples of mechanisms that can be used to broadly disseminate knowledge about effective behavior and treatment changes and create mechanisms to turn this knowledge into real and widespread client-level, practice-level, health system, and community-wide interventions. Second, physicians need to understand that they are not merely subject to these policies and initiatives. They can help formulate and shape them. This political involvement includes active participation in policy initiatives of professional associations, involvement in research and demonstration activities, keeping informed about policy proposals at the federal and state levels, and helping advance ideas for improving health behaviors by speaking up and working toward change. These changes go beyond health initiatives to involve improving housing, nutrition, transportation, and other arenas that play a role in the health of communities and cities. According to the IOM, the most successful interventions are aimed at families, neighborhoods and communities. Interventions are also most likely to be successful when legislative, media, and marketing efforts support them [50]. These broader policies may actually have the most potential impact in terms of developing sustainable lifestyle changes that reach all Americans, especially those with the greatest health needs. Within the aging population, those with greatest health needs include members of minority groups, recent immigrants, and the old-old. These groups are often overlooked when designing and implementing health promotion programs. It is important, however, to remember, for patients and for ourselves, you are never too old to benefit from prevention.

Nurse staffing and quality of care in nursing facilities

A study of 198 nursing facilities in Maryland tested the hypotheses that: 1) the presence of more RNs improves the quality of nursing care; and 2) increased numbers of all types of nursing staff improve the quality of nursing care, based on a multidimensional measure of quality of nursing care. Findings indicate that the ratio of RNs to residents is directly related to a measure of resident rights deficiencies. In addition, the ratio of total nursing staff to residents is directly related to a lower overall deficiency index and a higher quality of care score.

Characteristics of patients in a long-term care hospice setting

There are 34 hospices based in long-term care facilities in the United States. This study examines the characteristics of 697 hospice patients treated during a ten-year period in a long-term care based hospice setting, the Hospice of Washington, a unit of the Washington Home in Washington, DC. Characteristics of each patient, including age at admission, sex, race, marital status, referral source, payment source, diagnosis, and admission and discharge data were recorded. The age, race and sex characteristics of the Hospice's patients are not unusual, with the expected exception of a large and growing number of black patients. Interesting trends include decreasing length of stay, increasing non-cancer diagnoses including AIDS, decreased hospital referrals, and growing participation by HMOs.