Primary care outcomes and provider practice styles

The purpose of this study was to evaluate change in patient outcomes as a function of practice styles of primary care providers. A prospective, repeated-measures, correlational design was used. Data were collected about (1) providers' self-ratings of practice styles, inclusive of practice model, confidence, autonomy, collaboration, information giving, and job satisfaction, and (2) primary care patients' self-ratings of health status, functional status, information seeking, and satisfaction. When severity and comorbidity were controlled, physicians, nurse practitioners, and physician assistants produced equivalent outcomes; neither practice style nor provider type resulted in differences in health outcomes of primary care patients. Practice style did affect patient satisfaction. Patients were least satisfied with providers who scored high on collaboration and most satisfied with providers who scored low on the practice model. Neither provider type nor interpersonal attributes had an effect on health outcomes; sicker patients got better and healthy patients stayed that way.     

The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Regulatory,Billing, and Compliance Perspectives

The numbers of nurse practitioners and physician assistants are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. Some practices have instead embraced radiologist assistants. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside of radiology departments warrants closer review. The authors evaluate the recent literature and offer recommendations to radiology practices regarding both regulatory and scope-of-practice issues related to these professionals. Additionally, billing and compliance issues for care provided by nurse practitioners, physician assistants, and radiologist assistants are detailed. An analysis of the integration of these professionals into interventional and diagnostic radiology practices, as well as potential implications for medical education, is provided in the second part of this series.     

Nurse practitioners as primary care providers within the VA

We examined the perceptions of nurse practitioners (NPs) and physicians regarding NPs' roles as primary care providers within the Department of Veterans Affairs, thus suggesting possible reasons for the variation of NPs use. NPs and physicians from 7 Veterans Affairs hospitals were surveyed regarding perceptions and concerns about NPs' responsibilities. Quality of care was verified through outpatient services, laboratory results, and medications prescribed for 104,226 hypertensive or diabetic patients. Clinical findings suggest primary care for diabetic and hypertensive patients was comparable. Survey findings suggest physicians tended to underestimate what NPs do on their own for acute patients. Both groups expressed some concerns about expectations for NPs. To successfully integrate NPs into the primary care environment, health systems need to pay increased attention to differences in role perceptions among primary care providers.     

Quality assessment in primary military clinics of the Israel Defense Forces Northern Command

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.     

How Do Publicly Reported Medicare Quality Metrics for Radiologists Compare With Those of Other Specialty Groups?

PurposeTo characterize and compare the performance of radiologists in Medicare’s new Physician Compare Initiative with that of other provider groups.MethodsCMS Physician Compare data were obtained for all 900,334 health care providers (including 30,614 radiologists) enrolled in Medicare in early 2015. All publicly reported metrics were compared among eight provider categories (radiologists, pathologists, primary care, other medical subspecialists, surgeons, all other physicians, nurse practitioners and physician assistants, and all other nonphysicians).ResultsOverall radiologist satisfaction of all six Physician Compare Initiative metrics differed significantly from that of nonradiologists (all P ≤ .005): acceptance of Medicare-approved amount as payment in full, 75.8% versus 85.0%; Electronic Prescribing, 11.2% versus 25.1%; Physician Quality Reporting System (PQRS), 60.5% versus 39.4%; electronic health record participation, 15.8% versus 25.4%; receipt of the PQRS Maintenance of Certification Program Incentive, 4.7% versus 0.3%; and Million Hearts initiative participation, 0.007% versus 0.041%. Among provider categories, radiologists and pathologists demonstrated the highest and second-highest performance levels, respectively, for the two metrics (PQRS and MOC) with specialty-specific designs, but they ranked between fifth and eighth in all remaining non–specialty-specific metrics.ConclusionsThe performance of radiologists and pathologists in Medicare’s Physician Compare Initiative may relate to the extent to which metrics are tailored to the distinct aspects of their practices as diagnostic information specialists. If more physician participation in these programs is desired, more meaningful specialty-specific (rather than generic) metrics are encouraged.     

National Trends in the Utilization of Skeletal Radiography From 2003 to 2015

PurposeExamine recent trends in the use of skeletal radiography and assess the roles of various nonradiologic specialties in the interpretations.MethodsMedicare Part B fee-for-service claims data files from 2003 to 2015 were analyzed for all Current Procedural Terminology, version 4 (CPT-4) procedure codes related to skeletal radiography. The files provide examination volume, and we calculated utilization rates per 1,000 Medicare beneficiaries. Medicare’s physician specialty codes were used to determine the specialties of the providers. Total utilization rate trends were analyzed, as well as those for radiologists and nonradiologists. We determined which nonradiologist specialties were the highest users of skeletal radiography. Medicare place-of-service codes were used to identify the locations where the services were provided.ResultsThe total utilization rate per 1,000 of skeletal radiography within the Medicare population increased 9.5% from 2003 to 2015. The utilization rate for radiologists increased 5.5% from 2003 to 2015 versus 11.1% for nonradiologists as a group. Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians’ rate decreased 33.5%. Although radiologists do almost all skeletal radiography interpretation in hospital settings, nonradiologists do the majority in private offices. There has been strong growth in skeletal radiography in emergency departments, but a substantial drop in inpatient settings.ConclusionsThe utilization of skeletal radiography has increased more rapidly among nonradiologists than among radiologists. This raises concerns about self-referral and quality.     

Quality assessment of primary health care in a military setting

PURPOSE: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. METHODS: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. RESULTS: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. CONCLUSIONS: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.     

Criminal liability of physicians and other health care professionals in Hungary (review of case law between 1996-2000)

The authors examine the criminal cases involving physicians and other health care workers between January 1996 and December 2000 inclusive. in Hungary. The data are based on the registry of the Criminal Prosecutor's Office. Altogether 94 cases were initiated in this period of time, the accused of the criminal proceeding was a registered nurse in 9 cases, an ambulance paramedic in 5 cases, a pharmacist in 3, and a physician in 77 cases. In cases where registered nurses were involved, the most common act was negligent change of medication or providing inadequate custody of a patient in need, pharmacists were also accused for negligent change of medicinal products. In case of ambulance assistants the most common violation of the professional rules was diagnostic failure or not responding to the call in time. As to physicians, mostly primary care physicians were accused (29%), usually for failing to examine the patient or for diagnostic error, obstetricians-gynecologists (17 %) and traumatologists (12 %) were also frequently accused.     

An evaluation of provocative testing in the diagnosis of carpal tunnel syndrome

Carpal tunnel syndrome is a commonly known neurological entrapment disorder seen by primary care providers and occupational therapists. The purposes of this pilot study were to (1) identify the evaluation methods that primary care providers and occupational therapists use to diagnose carpal tunnel syndrome; (2) describe the procedures for evaluations that practitioners use in common; and (3) compare the frequencies of diagnostic results achieved with nerve conduction velocity testing vs. provocative testing. Three family care practitioners, two physician assistants, and four occupational therapists at four clinical sites participated over 4 months. Fifty-five subjects' hands (77 hands; 22 bilateral) were examined. Patients' ages ranged from 24 to 61 years, with mean of 42.5 years. Chi2 and Fisher's exact tests were used to examine diagnostic results. Practitioners differed slightly in evaluation methods and procedures used. The Tinel's sign results agreed with 57% (motor) and 64% (sensory) of positive nerve conduction velocity results (p > 0.05), whereas Phalen's test agreed with 83% (motor) and 85% (sensory) (p < 0.05). Although these results indicate that Phalen's test is more sensitive, they also accentuate the need for standardized testing based on the proposed use of the test results (screening vs. treatment).     

The relation between good communication skills on the part of the physician and patient satisfaction in a military setting

OBJECTIVE: The objective of this study was to assess the correlation between patients' view of the consultation and the assessment of an auditing physician on the same consultation. METHODS: A prospective study in military clinics was conducted. A board-certified family physician made a real-time semistructured assessment of the medical consultation. At the end of it, the patient was asked to fill in the Consultation Satisfaction Questionnaire. The degree of correlation between patients' satisfaction from consultation and the scores given by the auditing physician was evaluated. RESULTS: Twelve primary care physicians were evaluated. A total of 117 (76.5%) of 153 patients returned their questionnaires. A positive correlation was found between physician's communication skills and general satisfaction (r = 0.614), professional care (r = 0.367), and depth of relationship (r = 0.275) calculated from the Consultation Satisfaction Questionnaire. No correlation was found between patient satisfaction and other consultation skills. CONCLUSIONS: Good communication skills may enhance patient satisfaction. It may be advisable to investigate whether a training program to enhance the physician's communication skills can improve patient satisfaction.     

Nurse practitioner perceptions of facilitators and constraints to practice

The purpose of this study was to identify and explain conditions that served to constrain and/or facilitate the practice of Veterans Administration (VA) nurse practitioners (NPs). A 60% stratified random sample of all full-time VA NPs was surveyed. The sample represented NPs from the four hospital complexity levels and six geographic regions. A 92% response rate was obtained for a sample of 257 NPs. On the whole, VA NPs appeared to experience more facilitation than constraint. Areas that seemed to be especially positive for VA NPs were related to the direct delivery of care, and areas that interfered with their practice were related to administrative issues. NP practice is facilitated if there is a feeling of status, opportunity for professional growth, and NP personal satisfaction. Status can be influenced by independence in practice, support from top nurse administrators, and enough clerical support. Professional growth can be enhanced by providing opportunities for continuing education, research, physician back-up, and medical center committee membership. Personal satisfaction may be promoted through job security, independence in practice, fringe benefits, continuity of caseload, and opportunity for promotion. Throughout the analyses, independence repeatedly surfaced as an important criterion in the facilitation of NP practice.     

Ionizing Radiation Knowledge Among Emergency Department Providers

PurposeThe aim of this study was to assess knowledge of ionizing radiation exposure from diagnostic imaging examinations among emergency department (ED) providers.MethodsAn electronic questionnaire was distributed to ED providers in a five-hospital university-affiliated health care system. Providers included attending emergency medicine (EM) physicians, EM residents, and midlevel providers (MLPs) (nurse practitioners and physicians assistants). Data were collected and analyzed.ResultsOne hundred six of 210 providers (41 attending physicians, 32 residents, and 31 MLPs) completed the survey, for a response rate of 50.5%. More than two in five providers (44.6%) could not correctly identify which of six common imaging modalities used ionizing radiation. MLPs were more likely to incorrectly identify radiography (25%) and fluoroscopy (29%) as modalities that did not use ionizing radiation (P = .01 and P = .25 respectively). Fewer attending physicians (14.6%) than residents (37.5%) were not very comfortable or were uncomfortable explaining the risks of radiation to patients. Nearly half of attending physicians (47.5%) and nearly three-quarters of residents (71.9%) were not very comfortable, were uncomfortable, or were extremely uncomfortable explaining the amount of radiation in certain imaging tests to patients. MLPs were more likely to incorrectly rank a selection of imaging tests by radiation exposure (P = .002). MLPs were more likely to incorrectly answer a question on the effects of ionizing radiation on patients (P = .01).ConclusionsAmong ED providers, there are knowledge gaps regarding the presence and effect of ionizing radiation in diagnostic imaging tests. MLPs were more likely to make factual errors, while EM residents were least comfortable counseling patients about radiation risks.     

Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training

Advanced practice nurses (APN) who practice in the surgical subspecialty areas may have the opportunity to expand their scope of practice to include first assistant at surgery. Surgical APNs who practice as registered nurse first assistants (RNFA) should seek credentialing and apply for institutional privileges to assure the consumer of competent providers. Credentialing as an RNFA documents the educational learning process and skills acquired, and recognizes this area of expertise. The role of the APN as an RNFA at surgery is practiced within the specialty area of perioperative nursing which includes preoperative, intraoperative, and postoperative care. In this study, the nurse practitioners describe the role of the RNFA, its historical evolution over wartime, the required educational training, and the benefits of the role for patient care. The surgical nurse practitioner who undertakes training and education as a surgical RNFA is in an excellent position to provide patient care across the surgical continuum.     

The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications

The numbers of nurse practitioners (NPs) and physician assistants (PAs) are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. The use of radiologist assistants is growing in some radiology practices as well. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside radiology departments warrants closer review, particularly with regard to their potential influence on radiology education and medical imaging resource utilization. In this article (the second in a two-part series), the authors review recent literature and offer recommendations for radiology practices regarding the impact NPs, PAs, and radiologist assistants may have on interventional and diagnostic radiology practices. Their potential impact on medical education is also discussed. Finally, staffing for radiology departments, as a result of an enlarging nonradiology NP and PA workforce ordering diagnostic imaging, is considered.     

Using pictograms for communication

The U.S. Navy sponsors annual Pacific Partnership deployments to provide humanitarian and disaster relief training for the U.S. military, partner nations, nongovernmental organizations, and host nations. Communication between these groups and the local populations receiving medical care is problematic in that sufficient numbers of capable translators are often unavailable or vastly undertrained with respect to medical terminology and practice. In addition, should Pacific Partnership respond to a real disaster, adequate numbers of translators will likely be unavailable as a result of the disaster itself. Consequently, medical providers will require alternate methods of communication previously tested for efficacy and validity. One such method is the use of pictograms designed to represent common medical maladies. To determine whether pictograms meet the 85% congruence level required by the American National Standards Institute, 36 images were provided to English-speaking physician assistants and nurse practitioners for interpretation with three images repeated within the array to assess internal validity of the questionnaire. Of the 33 distinct images, 26 (79%) reached 85% congruence showing that validated images may be a method of communication in circumstances where medical providers and patients speak discordant languages.     

ACR intersociety conference 2003: radiologist assistants and other radiologist extenders

Improvements in imaging technologies are contributing to increases in the demand for radiology services. Efforts to match this rising demand are limited by the Centers for Medicare & Medicaid Services cap on resident positions and the challenges in obtaining appropriate visas and medical licenses for international medical graduates. This rising gap in the demand for and capacity to deliver radiology services has created a need for radiologist extenders. A variety of roles have been developed for these radiologist extenders, depending on the skills of the individuals and the subspecialty areas in which they work. Prominent among these are radiologist assistants, physician assistants, nurse practitioners, dosimetrists, and advanced-practice nuclear medicine technologists. Quality patient care is best accomplished when radiologist extenders function under the guidance of qualified radiologists, nuclear physicians, or radiation oncologists.     

A validated pediatric transport survey: how is your team performing?

INTRODUCTION: Understanding referring practitioners' satisfaction with pediatric transport services is useful for quality improvement. Formal survey methodology was applied to develop a pediatric transport satisfaction survey. SETTING: Large metropolitan area in the Southwestern United States. METHODS: A four-stage process was used to create a 20-item pediatric transport satisfaction survey. The final survey was analyzed for test-retest and internal consistency reliability, and surveys were mailed to a large practitioner base. RESULTS: The survey encompassed three domains: patient care, accessing the transport system, and communication. Test-retest and internal consistency reliability were good (final Cronbach alpha coefficient of 0.88.) Of the 229 providers responding, 69% were local (<60 miles), and 31% were served by our long distance transport team (>60 miles). Respondents reported that physicians selected the transport team in 82% of cases, whereas 9% reported that the charge nurse decided. Transport team selection was based on: (1) ease of initiation, (2) fastest arrival, (3) presence of a physician on the team, (4) stabilization time at the referring facility, and (5) team providing best follow-up. Satisfaction with our transport service was high, with a median survey score of 83 (interquartile [IQ] range, 74-92). Physicians and nurses reported equal satisfaction. CONCLUSION: Survey design methodology was successfully applied to assess satisfaction with pediatric transport. This transport survey offers a reliable measurement of providers' satisfaction with transport services.     

Expanding the role of the nurse practitioner in the deployed setting

Today's military is experiencing rapid advances in technology and in manpower utilization. The Army Medical Department is redesigning the structure and function of deployable hospital systems as part of this effort. The transformation of deployable hospital systems requires that a critical analysis of manpower utilization be undertaken to optimize the employment of soldier-medics. The objective of this article was to describe the use of nurse practitioners as primary care providers during deployment. The lived experiences of five nurse practitioners deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the literature clearly support expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.     

Physician assistants in academic radiology: the harborview experience

We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.