The extension of rheumatology services with physician assistants and nurse practitioners

The management of arthritis resides in the effect rheumatology specialists have on society as a whole, and a well-trained cadre of rheumatology specialists is imperative. However, the role of the rheumatologist providing care for a large population puts undue burden on that individual and on all the patients that depend upon him or her. Where team-based approaches to care are employed, efficiencies may arise that were not previously appreciated. Because the cost of medical labor is high and the pool of rheumatologists is decreasing, while at the same time the population is increasing in size, age, longevity, and sustainability of chronic diseases, a crisis in access is looming. One cost-effective strategy to manage such doctor shortages may be in areas other than the lengthy training necessary to produce a ‘board-certified’ rheumatologist. PAs and NPs have worked in rheumatology and many other specialties for over a quarter of a century. How well they perform in this role is slowly becoming known, and over 40 years of experience suggests that they may be more useful than previously understood. Exploring how PAs and NPs are deployed in rheumatology provides opportunities to examine methods for greater economies of scale.     

Successful colorectal cancer screening starts with primary care

Colorectal cancer screening is effective. Screening rates remain low, but that will change. All guidelines now recommend colorectal cancer screening, the value of screening is being promoted in the popular media, and insurers are beginning to pay for screening tests. For screening programs to be successful, good intentions must be backed by reminder systems, readily available patient information, and other changes in office practice. Currently recommended screening options accommodate a broad range of patient preferences and save lives, but none is ideal. Newer tests, such as virtual colonoscopy and stool-based DNA tests, will help if they offer greater sensitivity, specificity, or patient acceptability than current screening options.     

The employment of nurse practitioners and physician assistants in U.S. nursing homes

PURPOSE: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. DESIGN AND METHODS: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. RESULTS: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). IMPLICATIONS: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.     

Video endoscopy by nurse practitioners: a model for colorectal cancer screening

The use of paramedical personnel to perform sigmoidoscopy as a screening test for colorectal cancer has been advocated as a means of increasing the availability of this test to the population at risk. A model system has been developed utilizing flexible videosigmoidoscopy performed by nurse practitioners with videotape review by physician endoscopists. Of the 100 patients studied, 36 were found to have polyps. Near excellent concordance (k = 0.72) was observed between the nurse practitioner's findings and those of the physician. Using the physician's review as the standard, overall sensitivity and specificity of the nurse practitioner's examinations were 75% and 94%, respectively. In conclusion, videosigmoidoscopy performed by nurse practitioners and reviewed by physician endoscopists is a feasible approach to colorectal cancer screening since it is safe, provides videotape documentation to ensure quality control, and expands available resources for the performance of this examination.     

Evaluation of physician assistants in rural primary care.

The advent of physician assistants raises questions regarding their appropriate utilization and monitoring. To determine practice patterns of physician assistants in settings independent of training programs, we studied 14 primary care practices in the rural southeast. Detailed observations, including appropriateness of medical care, were made on 788 outpatient-provider encounters. Physician assistants handled minor medical problems well and 61% of the patients observed in these practices fitted this category. Three practice patterns were observed: all patients were seen by the assistant initially, followed by the physician; patients managed concurrently by physician and assistant were not preselected; and patients with specific problems were assigned to the assistant. Properly managed, each of these patterns yielded competent care. Using these observations, proposed models of management and audit are presented for each practice pattern.     

Issues related to colorectal cancer and colorectal cancer screening practices in women

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.     

On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Diagnostic judgments of nurse practitioners providing primary gynecologic care

OBJECTIVES: To determine the accuracy of experienced nurse practitioners' judgments of the probability of chlamydial infection of the cervix, to identify the clinical factors ("cues") related to the judgments, and to discern likely sources of judgment error. DESIGN: Cross-sectional study with prospective data collection. SETTING: Urban hospital-based clinic. PATIENTS: 492 nonpregnant women receiving primary gynecologic care. INTERVENTIONS: Four nurse practitioners recorded clinical data, tested women for chlamydial infection, and judged the probability of chlamydial infection using six categories: less than 1%, 1-4%, 5-9%, 10-24%, 25-50%, and greater than 50%. MEASUREMENTS AND MAIN RESULTS: Chlamydial infection was detected by immunofluorescent assay in 31 (6%) of the 492 women. Although the median probability judgment was 5-9%, judgments were only weakly related (p = 0.08) to actual rates of infection. In a multivariate analysis, eight clinical cues were independently (p less than 0.05) related to nurse practitioners' probability judgments: age less than 20 years; past chlamydial or gonococcal infection; new sex partner; partner with suspected genital infection; genito-urinary symptoms; cervicitis, purulent vaginal discharge; and malodorous vaginal discharge. A linear model based on the eight cues, weighted according to their regression coefficients, predicted chlamydial infection more accurately than did the nurse practitioners' actual judgments (ROC curve areas 0.69 vs. 0.58, respectively; p less than 0.05). However, only two of the eight cues (age less than 20 years and purulent vaginal discharge) were actually related to chlamydial infection in a second multivariate model; this model bad accuracy similar to that of an empirically derived prediction rule (ROC curve areas 0.77 and 0.80, p = 0.27). CONCLUSIONS: Nurse practitioners were often inaccurate in their diagnostic judgments. Our analyses suggest that this inaccuracy stemmed from both the inconsistent use of clinical cues and the use of cues that were not related to chlamydial infection. Therefore, interventions such as algorithms that promote consistency and accuracy in diagnostic use of relevant cues would be likely to improve their diagnostic judgments.     

Quality of patient care by nurse practitioners and physician's assistants: a ten-year perspective.

A remarkable development in primary care is the recent emergence of a new class of health professional: nurse practitioners and physician's assistants. These practitioners diagnose and treat a wide variety of medical problems, usually with supervision by physicians. Their clinical competence has been evaluated in over 40 studies. Twenty-one studies in which care given by nurse practitioners or physician's assistants was directly compared with that given by physicians are analyzed. These studies show that nurse practitioners and physician's assistants provide office-based care that is indistinguishable from physician care. Because these studies were limited in scope, there is no experimental basis for extending this conclusion to care given outside the office, care that is unsupervised, or care of the seriously ill patient.     

Direct observation of counseling on colorectal cancer in rural primary care practices

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.     

Differing attitudes toward virtual and conventional colonoscopy for colorectal cancer screening: surveys among primary care physicians and potential patients

OBJECTIVES: To investigate attitudes among primary care physicians and potential patients concerning "virtual" and conventional colonoscopy for colorectal cancer screening. METHODS: We sent 1000 questionnaires to primary care physicians by electronic or postal mail and administered 400 to potential patients. Questionnaires contained progressively detailed information about the tests and asked for choices based on information presented. RESULTS: One hundred eight-eight primary care physicians and 323 potential patients were included. Results indicated the following: 76.6% of potential patients and 47.3% of physicians initially preferred virtual colonoscopy because of its noninvasive nature; 23.6% of potential patients and 52.9% of physicians valued the ability of conventional colonoscopy to visualize the mucosa directly; and 67.4% of potential patients and 51.6% of physicians preferred virtual colonoscopy because it does not require sedation. Considering all information, most potential patients preferred virtual to conventional colonoscopy (60.2% vs 25.7%), whereas more physicians preferred conventional to virtual colonoscopy (44.9% vs 30.3%). Additionally, 82.3% of potential patients would comply more with recommendations for colorectal cancer screening, and 61.7% of physicians would refer more patients for screening, if virtual colonoscopy was available. CONCLUSIONS: Potential patients preferred virtual to conventional colonoscopy, whereas physicians favored conventional colonoscopy. Physicians placed more importance on the ability of conventional colonoscopy to visualize the mucosa directly, the opportunity for therapy, and cost. Potential patients were more encouraged than physicians by the availability of virtual colonoscopy for improving participation in colorectal cancer screening.     

<Emphasis Type="Italic">Chlamydia</Emphasis> screening and management practices of primary care physicians and nurse practitioners in California

BACKGROUND: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately.
OBJECTIVE: To assess the Chlamydia care practices of California primary care physicians and nurse practitioners.
DESIGN: Cross-sectional, self-report mail survey.
PARTICIPANTS: A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California.
MEASUREMENTS AND MAIN RESULTS: Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia -infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed.
CONCLUSIONS: The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.     

Improving colorectal cancer screening by targeting office systems in primary care practices: disseminating research results into clinical practice

BACKGROUND: Randomized trials have shown the efficacy of an office systems approach in improving colorectal cancer (CRC) screening behaviors; its feasibility in real-world primary care practices has not been well studied. METHODS: Between August 1, 2000, and December 1, 2001, we enrolled 185 primary care clinicians identified through purchased database lists. At the end of follow-up (December 31, 2002), 127 clinicians had completed preintervention and postintervention questionnaires. Trained staff from the American Cancer Society visited practices and identified areas for improvement in CRC screening. They provided clinicians with resources, tools, and support to facilitate positive change. We defined 5 clinician behavior areas related to successful CRC screening, including educating patients, identifying patients due for screening, enabling patient compliance, monitoring patient compliance, and notifying patients of their test results. We measured these areas before and after the intervention using questionnaires and data extracted from medical records. RESULTS: We demonstrated improvements in the passive use of posters and brochures about CRC screening (baseline, 20.5% and follow-up, 69.3%; P<.001) and in the monitoring of fecal occult blood tests using manual tracking systems (baseline, 20.6% and follow-up, 37.3%; P<.05). Based on medical records data among 551 patients, we found a statistically significant increase in the number of patients who became up-to-date with CRC screening recommendations and tests (P< .001 for both). CONCLUSION: Methods shown to improve CRC screening processes in protocol-driven randomized trials may be effective in community practice, and wider dissemination of these strategies shows promise to increase CRC screening.