The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

OBJECTIVES: Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine. METHODS: All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited. RESULTS: Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy. CONCLUSIONS: Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.     

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.     

Prescribing home oxygen therapy. What the primary care physician needs to know.

Physicians who prescribe home oxygen therapy often find it difficult and time-consuming to complete the required certification of medical necessity because of a lack of in-depth knowledge concerning the Medicare requirements and treatment options. The Health Care Financing Administration (HCFA) now mandates that the physician or an employee of the physician complete the form to certify medical necessity (form HCFA-484); otherwise, the home oxygen supplier cannot be reimbursed for equipment and service. Since long-term oxygen therapy is essential to increase survival and to improve the quality of life for patients with hypoxemia due to chronic pulmonary disease, it is imperative that the primary care physician understand the indications and requirements for therapy and be able to order the most appropriate equipment for the therapeutic needs. This article is intended to provide the physician with the information needed to properly prescribe home oxygen therapy.     

Self-perceived met and unmet care needs of frail older adults in primary care

In order to provide adequate care for frail older adults in primary care it is essential to have insight into their care needs. Our aim was to describe the met and unmet care needs as perceived by frail older adults using a multi-dimensional needs assessment, and to explore their associations with socio-demographic and health-related characteristics. Cross-sectional baseline data were used from the Frail older Adults: Care in Transition (ACT) study in the Netherlands, consisting of 1137 community dwelling frail older adults aged 65 and above. Patients were recruited through 35 primary care practices. Self-perceived care needs were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Socio-demographic characteristics included age, sex, partner status and educational level. Health-related characteristics included functional capacity, hospital admissions, chronic diseases and the degree of frailty. Frail older adults reported on average 4.2 care needs out of 13 CANE topics, of which 0.5 were unmet. The physical and environmental domain constituted the highest number of needs, but these were mostly met. Unmet needs were mainly found in the psychosocial domain. Regression analyses revealed that Activities of Daily Living (ADL) limitations and a higher frailty score were the most important determinants of both met and unmet care needs. A younger age and a higher educational level were associated with the presence of unmet care needs.     

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.     

Medication management in older adults and interprofessional education: A needs assessment

ABSTRACT

Elderly, multi-morbid patients are at high risk for suffering adverse drug events. Safe medication management is a key process in preventing these adverse events, and requires interprofessional teamwork. We performed a needs assessment survey of graduating medical students and faculty to evaluate student training in medication management, in particular students’ preparedness in the three minimum geriatrics competencies pertaining to medication management, interprofessional educational opportunities, and optimal learning methods. Response rates were 45/105 (43%) for students and 38/93 (41%) for faculty. The majority of students felt that they did not receive sufficient training in medication management in older adults. Faculty either agreed with students or were unsure whether students received sufficient training. Neither students nor faculty felt that students were extremely prepared to carry out the three minimum geriatrics competencies at the time of medical school graduation. Students and faculty identified direct patient care experiences as the optimal learning method, and inappropriate medications as the highest priority topic. Students and faculty felt that students do not receive sufficient interprofessional educational opportunities. The results of this study are currently being used to create customized interprofessional educational experiences for medical students related to medication management in older adults.     

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.     

Health promotion in older adults. Prescribing exercise for the frail and home bound

Some degree of physical activity is always preferable to a sedentary lifestyle. For home bound elderly, with limited mobility and strength, physical activity should be focused on "functional fitness," such as performing activities of daily living, transfers, and mobility. We examine the benefits of exercise for frail home bound elderly, potential barriers to exercise, and ways to initiate a physical activity program.     

Assessment and counseling of older drivers. A guide for primary care physicians

Despite the proliferation of motor vehicles and the increase in number of miles traveled in this country during the past century, motor vehicle safety has improved. The annual death rate has declined dramatically since it was first measured in 1925. However, motor vehicle accidents remain the leading cause of injury death in children and young and middle-aged adults and the third leading cause of years of potential life lost prior to age 65, behind cancer and heart disease. There are some regional and vehicular factors, with higher motor vehicle death rates in the southeast and in scattered western states. The highest rates of vehicular fatalities are in the youngest and oldest drivers, their passengers, and in all who drive under the influence of alcohol or as a passenger in a car driven by someone under the influence. Medical conditions may also compromise driving ability and/or increase fatality rate in adults of all ages. These conditions and situations, particularly as applied to older adults, are presented here.     

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES: This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider. DESIGN: A randomized, prospective controlled trial involving 41 primary care sites. SETTING: Primary care practice sites. PARTICIPANTS: 49 older adults age 60 and older not previously screened for UI by their primary care doctor. MEASUREMENTS: Demographic data, self-reported bladder-control information using questionnaires, and health status. RESULTS: Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%). CONCLUSIONS: Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.     

Diabetes care processes and outcomes in patients treated by nurse practitioners or physicians

PURPOSE: The purpose of this study was to compare selected diabetes care processes and outcomes of nurse practitioners (NPs) and physicians (MDs) in the primary care of adults with type 2 diabetes. METHODS: Adults with type 2 diabetes and no regular source of primary care were enrolled from the emergency room and randomized to an NP or MD practice. Chart reviews were conducted to assess processes of care; patient interviews and hemoglobin A1C (A1C) testing were performed to measure patient outcomes. RESULTS: NPs were more likely than MDs to document provision of general diabetes education and education about nutrition, weight, exercise, and medications. They were more likely to document patient height, urinalyses results, and A1C values. No differences were found in documenting current medications; alcohol, illicit drug, or tobacco use; depression; weight and blood pressure; foot and cardiovascular exams; blood glucose and creatinine testing; or referral to ophthalmologists. No differences were found in patient outcomes. CONCLUSIONS: This study provides preliminary evidence of interdisciplinary differences in the processes of care employed by primary care NPs and MDs in caring for patients with type 2 diabetes. NPs documented the provision of diabetes education and selected monitoring tests more frequently than MDs; however, these differences were not reflected in 6-month patient outcomes.     

Self-reported comorbidities,perceived needs,and sources for usual care for older and younger homeless adults

BACKGROUND: While older individuals who are homeless tend to be in poorer health, it is less clear how they view their health care needs and whether their self-reported patterns for accessing health services differ from younger homeless counterparts. METHODS: Cross-sectional, community-based survey of homeless adults in Pittsburgh and Philadelphia using face-to-face interviews from population proportionate sampling of sites and random sampling of subjects. Survey questions included physical and mental health comorbidities, self-reported health care, social services and personal needs, means of economic support, and sources for usual health care. For analysis purposes, respondents were grouped by age 18 to 49 years old and 50 years old or older. RESULTS: Overall, 531 adults were interviewed, with 74 respondents 50 years old or older (13.9%). Older homeless persons were 3.6 times more likely to report a chronic medical condition, 2.8 times more likely to have health insurance, and 2.4 times more likely to be dependent on heroin than homeless persons less than 50 years old. However, they also tended to use shelter-based clinics and street outreach teams more commonly as their source of usual care (20.9% vs 10.6%, P=.02) and were significantly less likely to report a need for substance abuse treatment despite high rates of abuse. CONCLUSION: Older homeless adults have a greater disease burden than their younger counterparts. However, it is unclear whether these needs are being appropriately identified and met. There is a need for specific and targeted outreach to connect them to appropriate services.