Nurse practitioners and physician assistants revisited: do their practice patterns differ in ambulatory care?

The education and regulation of nurse practitioners and physician assistants would suggest unique role differentiations and practice functions between the professions. This study explored to what extent their practice patterns in primary care actually differ. It was hypothesized that the primary care services provided by nurse practitioners would tend to be women and family health services, health prevention and promotion oriented, provided to minority and socioeconomic disadvantaged patients, and less dependent on physician supervision. In contrast, the services provided by physician assistants would more likely be medical/surgical oriented; diagnostic, procedural, and technical in nature; likely to be in rural areas; and more dependent on physician supervision. The study used patient data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Although some differences emerged, the argument is not compelling to suggest strong, unique, practice differences across all ambulatory care settings between the two types of nonphysician providers. It is the specific type of ambulatory setting that influences the practice pattern for both provider groups. If practice patterns are less distinctive than previously believed, more opportunities for interdisciplinary education need to be explored, and health policies that promote a discipline-specific primary care workforce may need to be reexamined.     

Characteristics of patient visits to nurse practitioners in hospital outpatient departments.

Nurse practitioners (NPs) are the largest and the fastest growing groups among nonphysician practitioners in the United States. However, there has been lack of studies on the supply, demand, and use of nurse practitioners in hospital outpatient departments (OPDs) across the nation. Using the National Hospital Ambulatory Medical Care Survey (1997-2000), this study describes patient visits to NPs in general medicine, pediatrics, and obstetrics/gynecology clinics in hospitals across the nation. The percentage of patient visits involving NPs increased from 5.9 percent in 1997 to 7.3 percent in 2000. NPs have greater roles in hospital OPDs in nonmetropolitan areas than in metropolitan areas. Regional difference in patient visits to NPs supports the relationship between the practice environment and the use of NPs. As expected, NPs continue to serve the health care needs of women and children in hospital OPDs. Of all OPD visits with a NP service, NPs saw patients with no presence of a physician in 82 percent of these visits. As the role of the NP evolves in the U.S. health care delivery system, further studies on the clinical practice of NPs in hospital OPDs can help evaluate the impact of NPs in providing quality of patient care at minimum cost.     

ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions

OBJECTIVES: The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations. METHODS: A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau. RESULTS: Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions. CONCLUSIONS: Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.     

Do nurse practitioners make a difference in provision of health counseling in hospital outpatient departments?

PURPOSE: This study examined whether nurse practitioners (NPs) had any impact on the type and amount of health counseling provided during patient visits to hospital outpatient departments (OPDs). DATA SOURCES: This is a secondary data analysis of the National Hospital Ambulatory Medical Care Survey from 1997 to 2000. Only patient visits to hospital OPDs were included. Rates of health counseling provided at patient visits involving an NP were compared with those without an NP. Adjusted odds ratio was reported separately for each type of health counseling provided at patient visits for nonillness care, for chronic problems, and for acute problems. CONCLUSIONS: Health counseling for diet, exercise, human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention, tobacco use, and injury prevention are more likely to be provided at nonillness care visits involving an NP than at those not involving an NP. The presence of an NP is associated not only with higher rates of counseling for diet, exercise, and tobacco use provided at patient visits for chronic problems but also with higher rates of counseling for diet and HIV/STD prevention provided at patient visits for acute problems. IMPLICATIONS FOR PRACTICE: This study indicates an important role NPs can play in providing preventive services in outpatient hospital departments. The findings reflect the emphasis of the NP education on health counseling and patient education in clinical practice.     

Primary reasons for ED visits and procedures performed for patients who saw nurse practitioners.

INTRODUCTION: Little is known, from a national perspective, about what types of patients are seen by nurse practitioners in the emergency department. METHODS: Data from 1545 participating emergency departments across the United States during 1997, 1998, 1999, and 2000 were collected from nationally representative samples of urban and rural hospitals using the National Hospital Ambulatory Medical Care Surveys. Results Nurse practitioners saw 5.76 million ED patients during the 4-year period. Using the Reason for Visit Classification developed by the National Center for Health Statistics, the primary category for patients seen by nurse practitioners was classified as "Injury by type and/or location." The types of injuries in this category were lacerations and cuts to an upper extremity and facial area; injuries to the head, neck, and face; and foreign bodies in the eye. The next most common category was classified under "General symptoms." Nurse practitioners saw patients in this category with symptoms of chest pain, side or flank pain, fever, and edema. DISCUSSION: The findings from this study provide insight into the types of patient visits seen by nurse practitioners in emergency departments in the United States and the services and procedures that were received by patients.     

Influence of Ambulance Arrival on Emergency Department Time to Be Seen

Objectives. For a limited number of presenting complaints, arrival by ambulance has been shown in some emergency departments to decrease time to be seen by a physician. We sought to determine if this time advantage could be demonstrated as a national trend over a variety of presenting complaints. Methods. A secondary analysis was performed on the National Hospital Ambulatory Medical Care Survey, a national probability sample of emergency department visits. To compare waiting times between patients arriving by ambulance andthose arriving by walk-in, a survival analysis was performed using univariate andmultivariate Cox proportional hazards models. Primary variables of interest were mode of arrival, waiting time to see physician, andimmediacy to be seen (triage category). The weighted values were utilized to produce national estimates. Patients who left without being seen were treated as right censored data. Results. A total of 61,130 records, weighted to represent 268.3 million emergency department visits from 1997 to 2000, were included in the analysis. Patients arrived by ambulance in 14.4% of these cases. Median wait time for patients arriving by ambulance was 14.1 minutes (95% confidence interval [CI], 4.3 to 34.2) as compared with 26.0 minutes (95% CI, 11.5 to 55.1) for patients who arrived by walk-in. In the multivariate analysis, arrival by ambulance offered a 25.0% (95% CI, 19.0% to 31.6%) time advantage over walk-in anda 40.8% (95% CI, 23.5% to 58.7%) time advantage over arrival by public service. Conclusions. Arrival by ambulance offered a time to be seen advantage for a broad range of presenting complaints in the National Hospital Ambulatory Medical Care Survey across all triage categories.     

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

Objective

The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).

Methods

We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.

Results

From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both P_trend < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).

Conclusions

Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.     

Treatment cost of acute exacerbations of chronic bronchitis.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged > or =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged > or =65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients aged > or =65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged > or =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged > or =65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged > or =65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.     

Chronic obstructive pulmonary disease surveillance--United States, 1971-2000

PROBLEM/CONDITION: Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema but has been defined recently as the physiologic finding of nonreversible pulmonary function impairment. This surveillance summary reports trends in different measures of COPD during 1971-2000. REPORTING PERIOD COVERED: This report presents national data regarding objectively determined COPD (1971-1994); COPD-associated activity and functional limitations (1980-1996); self-reported COPD prevalence, COPD physician office and hospital outpatient department visits, COPD hospitalizations, and COPD deaths (1980-2000); and COPD emergency department visits (1992-2000). DESCRIPTION OF SYSTEMS: The Centers for Disease Control's National Center for Health Statistics conducts the National Health Interview Survey annually, which includes questions concerning COPD and activity limitations. The National Center for Health Statistics collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient department data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. Data regarding pulmonary function were obtained from the National Health and Nutrition Examination Surveys (NHANES) I (1971-1975) and III (1988-1994), and data regarding functional limitation were obtained from NHANES III, Phase 2 (1991-1994). RESULTS: During 2000, an estimated 10 million U.S. adults reported physician-diagnosed COPD. However, data from NHANES III estimate that approximately 24 million United States adults have evidence of impaired lung function, indicating that COPD is underdiagnosed. During 2000, COPD was responsible for 8 million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths. During the period analyzed, the most substantial change was the increase in the COPD death rate for women, from 20.1/100,000 in 1980 to 56.7/100,000 in 2000, compared with the more modest increase in the death rate for men, from 73.0/100,000 in 1980 to 82.6/100,000 in 2000. In 2000, for the first time, the number of women dying from COPD surpassed the number of men dying from COPD (59,936 vs 59,118). Another substantial change observed is that the proportion of the population aged < 55 years with mild or moderate COPD, on the basis of pulmonary function testing, decreased from 1971-1975 to 1988-1994, possibly indicating that the upward trends in COPD hospitalizations and mortality might not continue. INTERPRETATION: COPD is a major cause of morbidity, mortality, and disability in the U.S. Despite its ease of diagnosis, COPD remains an underdiagnosed disease, chiefly in its milder and more treatable form.     

Impact of smoking on respiratory illness-related outpatient visits among 50- to 75-year-olds in the United States

BACKGROUND: Although it is generally agreed that tobacco use poses an enormous public health problem, payment and reimbursement for smoking-cessation interventions by financially stretched national health systems remain controversial. OBJECTIVE: The purpose of this study was to estimate the number and cost of excess respiratory illness-related visits attributable to smoking among older adults in the United States. METHODS: The 1995 and 1996 National Ambulatory Medical Care Survey databases were analyzed to estimate attributable risk in the population by age, sex, and smoking status among adults 50 to 75 years of age. Cost estimates for ambulatory physician visits were based on data from a major New England insurer using combined 1995 and 1996 information. Cost estimates were then developed for patients who had a respiratory-illness related diagnosis. RESULTS: Smoking was responsible for 5.1% (1,358,565) and 5.7% (1,452,761) of respiratory illness-related physician visits in 1995 and 1996, respectively. The costs (in 1998 dollars) of physician visits attributable to smoking were $69,205,301 and $74,003,645 in 1995 and 1996, respectively. CONCLUSIONS: Smoking increases health services utilization related to respiratory illness, thereby substantially increasing health care costs. Smoking-cessation programs may help reduce physician office visits related to respiratory illness, as well as the overall societal burden of smoking.     

Client characteristics and practice patterns of nurse practitioners and physicians

This study's purpose was to describe the practice patterns of nurse practitioners (NPs) in Tennessee--specifically, the demographic characteristics and health problems of their clients and the therapeutic services they provide. A random sample of NPs practicing 20 or more hours per week in primary care in Tennessee provided data on a total of 680 clients seen during one selected day of care. An instrument adapted from the National Ambulatory Medical Care Survey (NAMCS) allowed comparison of the NP findings with a national survey of office-based physicians in five areas: client demographics, client health status, diagnostic tests ordered, therapeutic interventions provided, and client disposition. Although many similarities were seen, differences included the tendency of NPs to care for more younger and female clients, to perform fewer office surgical procedures, and to provide more health teaching/counseling interventions.     

Differences in the number of services provided by nurse practitioners and physicians during primary care visits

BackgroundDue to differential training, nurse practitioners (NPs) and physicians may provide different quantities of services to patients.PurposeTo assess differences in the number of laboratory, imagining, and procedural services provided by primary care NPs and physicians.MethodsSecondary 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.FindingsOn 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.DiscussionNPs provide fewer laboratory and imaging services than physicians during primary care visits.     

Disease patterns in homeless children: a comparison with national data.

Although homeless children have increased in numbers as poverty has become feminized, minorities have become poorer, and low-income housing has become less accessible, little is known of their health problems. This study compared the health problems of a group of uninsured and homeless children visiting a free, nurse-managed, primary care clinic on Los Angeles' Skid Row with data from children's primary care visits to pediatricians and general and family physicians sampled in the National Ambulatory Medical Care Survey. Diagnoses were classified into the following health service categories: (a) acute, (b) communicable, and (c) chronic disease; (d) preventive and (e) injury care. Comparisons indicated that services to homeless children differed significantly from reimbursed services in the national sample in all categories except chronic disease. Demographic analysis indicated that homeless children were predominantly Hispanic Americans. When data from Hispanic children were examined, the pattern of differences between the homeless and National Ambulatory Medical Care Survey diagnostic categories persisted. This study shows the variations in nursing care which a group of high-risk, severely impoverished, uninsured children require.     

Magnitude of national ED visits and resource utilization by the uninsured

Background

For nearly 51 million persons in the United States who lack health care insurance, the emergency department (ED) functions as a safety net where no patient is denied care based on ability to pay, and much public rhetoric has characterized ED utilization by uninsured patients. We estimated national ED utilization by uninsured patients and compared uninsured and insured ED patients in terms of demographics, diagnostic testing, disposition and final diagnoses.

Methods

We analyzed data from the National Hospital Ambulatory Medical Care Survey (2006-2009) stratified by insurance status. Demographic data, diagnoses, testing, and procedures performed in the ED were tabulated for each visit. Weighted percentages provided by National Hospital Ambulatory Medical Care Survey were used to estimate national rates for each variable, and multivariate models were constructed for predicting testing, procedures, and admission.

Results

The 135 085 ED visits represent 475 million patients visits, of which 78.9 million (16.6%) were uninsured. Compared with insured patients, uninsured patients were more often male (51.1% vs 44.3%) and younger (age 18-44 years, 66.2% vs 35.4%). Uninsured patients had lower rates of circulatory/cardiovascular (7.5% vs 4.1%) and respiratory diagnoses (14.6% vs 11.8%). Uninsured patients had fewer diagnostic tests and procedures and fewer hospital admissions than those with insurance. In our multivariate models, insurance status was predictive of testing and procedures but not hospital admission.

Conclusions

Uninsured patients account for approximately 20 million or 1 in 6 ED visits annually in the United States and have differences in demographics, diagnoses, and ED utilization patterns from those with insurance.