Physician attitudes toward physician extenders: a comparison of nurse practitioners and physician assistants.

A survey of all physicians in the Eighth District Medical Society (Western New York) was conducted in 1975 to determine physician attitudes toward employment of and task delegation to nurse practitioners. The results of this study and one other similar study of nurse practitioners are compared to results of two previous studies examining physician attitudes toward physician assistants. It appears that physicians are somewhat more willing to employ and delegate tasks to a physician's assistant. Some correlates of physician attitudes toward each of the two types of physician extenders are also compared and discussed.     

Ethical conflict in nurse practitioners and physician assistants in managed care

BACKGROUND: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. OBJECTIVE: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. METHODS: A cross-sectional self-administered mailed questionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Respondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict. RESULTS: Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient's condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance. DISCUSSION: NPs and PAs are experiencing ethical conflict often associated with their perceived professional obligations to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients' needs within a constrained healthcare system.     

Practical and legal implications of nurse practitioners and physician assistants in cystoscopy

Due to looming physician shortages and the increase in demand for quality medical care for the newly insured, as well as the aging Baby Boomer population, there has never been a more important time for physicians, administrators, and the public to endorse and develop the role that nurse practitioners (NPs) and physician assistants (PAs) will play in the future of medical practice. One way to begin to address this problem is by expanding investments in training, competencies, and certification for NPs and PAs in performing minor procedures, such as cystoscopy, which is currently being performed by NPs and PAs across the United States and United Kingdom safely and with consistently high quality outcomes.     

Training of nurse practitioners and physician assistants to perform screening flexible sigmoidoscopy

PURPOSE: To describe the colorectal cancer-screening program at Harvard Vanguard Medical Associates, a large multispecialty medical group, in which nurse practitioners (NPs) and physician assistants (PAs) perform screening flexible sigmoidoscopies. DATA SOURCES: Scientific literature, consensus statements and guidelines, and the protocol utilized to train NPs and PAs to perform flexible sigmoidoscopy. Data from 9,500 screening procedures are presented. CONCLUSIONS: In comparison with gastroenterologists, trained NP and PA endoscopists perform screening flexible sigmoidoscopy with similar accuracy and safety but at lower cost. IMPLICATIONS FOR PRACTICE: Screening flexible sigmoidoscopy performed by NPs and PAs may increase the availability and lower the cost of flexible sigmoidoscopy for colorectal cancer screening.     

Characteristics of patient visits to nurse practitioners and physician assistants in hospital outpatient departments

Many authors have described differences between nurse practitioners and physician assistants. Most studies have compared physician with nonphysician providers' practice. Few studies have compared nurse practitioners and physician assistants, and none has used a national data base. This exploratory, atheoretical research examined which of the following characteristics predicted patients being seen by nurse practitioners and physician assistants: patient and hospital demographics, diagnosis, diagnostic/screening services, therapeutic services, and disposition of the visit. The data set used for analysis was the 1992 National Hospital Ambulatory Medical Care Survey. Based on a multistage probability design yielding national estimates for patient visits in hospital outpatient settings, the National Hospital Ambulatory Medical Care Survey showed that there were 2,847 weighted patient visits to either nurse practitioners or physician assistants (4.6 million patient visits using national estimates). Results of multivariate logistic regression suggest that nurse practitioners were the most likely nonphysician provider for outpatients receiving more health promotion and counseling (therapeutic) services and for those needing women's and children's services. Outpatients in rural areas predicted visits to physician assistants. As more nonphysician providers enter the work force, the results of this research may assist with understanding the utilization of nurse practitioners and physician assistants in primary care.     

Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma

Objective

The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.

Methods

We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).

Results

Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled β-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (−6 points; 95% CI, −9 to −3 points). Supervised MLPs provided similar quality of care to that of physicians.

Conclusions

The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.     

Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit

Introduction

Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care.

Methods

We conducted a quasi experimental study in seven ICUs in an academic hospital and a hybrid academic/community hospital. After a period of self-reporting, a one-time monetary incentive of $2,500 was offered to 39 affiliates in each ICU in which every affiliate documented greater than 75% of their time devoted to patient care over a 6-month period in an effort to understand how affiliates allocated their time throughout a shift. Documentation included billable time (critical care, evaluation and management, procedures) and a new category ("zero charge time"), which facilitated record keeping of other patient-care activities.

Results

At baseline, no ICUs had documentation of 75% patient-care time by all of its affiliates. In the 6 months in which reporting was tied to a group incentive, six of seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased from 53% to 84%. Zero-charge time accounted for an average of 21% of each shift. The most common reason was rounding, which accounted for nearly half of all zero-charge time. Sign out, chart review, and teaching were the next most common zero-charge activities. Documentation of time spent on billable activities also increased from 53% of an affiliate's shift to 63%. Time documentation was similar regardless of during which shift an affiliate worked.

Conclusions

Approximately two thirds of an affiliate's shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but not reimbursable patient care. Understanding how affiliates spend their time and what proportion of time is spent in billable activities can be used to plan the financial impact of staffing ICUs with affiliates.     

The public's view of physicians' assistants and nurse practitioners: a survey of Baltimore urban residents.

This study of public attitudes toward physicians' assistants and nurse practitioners finds that the public regards the two groups of health workers as remarkably similar. A telephone survey of 2,583 households in the Baltimore, Maryland, metropolitan area indicates that about half the population have heard of a PA or NP, though only 4 per cent report receiving care from such workers. In this urban sample, respondents accepted the principle that important medical care functions can be delegated, as long as the PA or NP is considered assistant to the physician. The public reported more acceptance of tasks performed by nurse practitioners than by physicians' assistants, though the differences are small.     

Skill mix change between physicians,nurse practitioners,physician assistants,and nurses in nursing homes: A qualitative study

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.