Using Medicare data to assess nurse practitioner–provided care

BackgroundTo mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns.PurposeThis study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician.MethodsWe performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics.DiscussionStates with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas.ConclusionsApproximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.     

The knowledge of low back pain management between physical therapists and family practice physicians

Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians.

Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests.

Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30–4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19–0.66]).

Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.     

Educational needs in the diagnosis and management of pediatric functional constipation: a US survey of specialist and primary care clinicians

Objectives: The goal of this study was to identify opportunities among gastroenterologists and gastroenterology nurse practitioners (NPs)/physician assistants (PAs) for continuing medical education (CME) related to functional constipation.

Methods: An online, case-vignette survey was designed to identify and quantify practice patterns of pediatric gastroenterology clinicians. Case vignettes are a validated method for assessing clinician practice patterns. The survey consisted of three patient cases: a 3-year-old female with a 6-month history of constipation; a 6-year-old male with a 1-year history of constipation refractory to treatment and a sacral dimple with nearby tuft of hair; and a 16-year-old male with a 10-year history of constipation, and a sullen, depressed mood. Survey responses were compared to NASPGHAN guideline recommendations for diagnosis and management to identify areas where additional education may be beneficial.

Results: Responses were collected from 197 gastroenterologists, 116 gastroenterology NPs/PAs, and 206 pediatrician/primary care clinicians. Several of the practice patterns observed suggest opportunities for future CME: low use of applicable Rome III diagnostic criteria; approximately 85% recommended testing beyond what is recommended for the 3-year-old patient; over 1/3 did not perform several recommended tests for the 6-year-old patient; and over 25% did not refer the 16-year-old patient for psychological evaluation. Further, there was little consensus in treatment approach among the three clinician groups. Primary care familiarity with NASPGHAN guidelines was low.

Conclusions: CME programs focusing on applying diagnostic criteria, matching diagnostic workup to patient presentation, treatment selection, and identifying patients who may benefit from psychological evaluation may fill knowledge and practice gaps of clinicians who manage pediatric patients with functional constipation.     

Case Management by Physician Assistants and Primary Care Physicians vs Emergency Physicians

Objectives : To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).
Methods : An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.
Results : The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows:

Conclusion : The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.     

The impact of ethics and work-related factors on nurse practitioners' and physician assistants' views on quality of primary healthcare in the United States

PurposeNurse practitioners (NPs) and physician assistants (PAs) provide primary care services for many American patients. Ethical knowledge is foundational to resolving challenging practice issues, yet little is known about the importance of ethics and work-related factors in the delivery of quality care. The aim of this study was to quantitatively assess whether the quality of the care that practitioners deliver is influenced by ethics and work-related factors.MethodsThis paper is a secondary data analysis of a cross-sectional self-administered mailed survey of 1,371 primary care NPs and PAs randomly selected from primary care and primary care subspecialties in the United States.ResultsEthics preparedness and confidence were significantly associated with perceived quality of care (p < 0.01) as were work-related characteristics such as percentage of patients with Medicare and Medicaid, patient demands, physician collegiality, and practice autonomy (p < 0.01). Forty-four percent of the variance in quality of care was explained by these factors.ConclusionsInvesting in ethics education and addressing restrictive practice environments may improve collaborative practice, teamwork, and quality of care.     

Comparison of the Quality of Patient Referrals From Physicians,Physician Assistants,and Nurse Practitioners

ObjectiveTo compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists.Patients and MethodsWe conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index.ResultsFactor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001).ConclusionThe quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.     

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BackgroundHealth care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently.ObjectivesInvestigate the NP role in care delivery—primary care providers with the own patient panels or delivering episodic care—within their organizations and understand how work environments affect their role.DesignA cross-sectional survey design was used to collect data from primary care NPs.SettingsThe study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs.Participants807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%.MethodsThe survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery.ResultsAbout 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio = 2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled.ConclusionsNPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.     

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.     

Primary Care Physician Attitudes and Practice Patterns in the Management of Obese Adults: Results from a National Survey

Abstract

Purpose: Obesity remains a serious public health problem. The purpose of this study was to identify the current attitudes and practices of primary care physicians (PCPs) with respect to obesity. Methods: A survey was systematically developed and administered electronically to PCPs, who received a small honorarium for their time. Results were analyzed to identify specific attitudes and practices and their associations with each other and with demographic and other variables. Results: Physicians expressed little confidence in their ability to manage obesity. In general, however, they believed that obesity could be successfully managed. Lifestyle changes were perceived to be the most effective available method for patients to lose weight, and respondents were more likely to recommend this approach over pharmacotherapy or bariatric surgery. Respondents perceive the greatest barrier to managing obese patients to be a lack of patient motivation. Physicians were significantly more likely to initiate discussions with obese patients about their weight if they believed they had positive attitudes about and knowledge of weight management, and adequate resources to manage the problem. Conclusions: Physicians report a lack of confidence in managing obesity. Lack of patient motivation is perceived to be the greatest barrier. Physicians with greater knowledge, more positive attitudes toward obesity management, and access to more resources are more likely to provide weight management in primary care settings.     

Factors influencing clinical consistency and variability in voice prosthesis management

Abstract

Purpose: Anecdotally it is recognised that management of tracheoesophageal speech (TES) post-laryngectomy varies between speech language pathology (SLP) services and clinicians. This study reviewed patterns of practice for TES management to examine patterns of practice and explore factors influencing variability.

Method: A national survey was completed by SLP’s from clinical services which manage TES. This online survey examined demographic and caseload information, initial voice prosthesis (VP) placement and procedures, VP cleaning and care recommendations, humidification management, equipment and service provision, and service delivery options at each site.

Result: Lead clinicians from 34 sites (85% response rate) responded. Most clinical practice regarding initial VP insertion and management, as well as the timing and delivery of voice rehabilitation was highly consistent. Patient use of antifungal medications, TES and associated equipment provision, humidification management immediately post-surgery and some aspects of initial VP insertion were variable between services. The nature of the clinical setting, equipment funding and level of research evidence influenced variability in practice.

Conclusion: Variability exists in a number of aspects of practice across Australian services offering TES management. Sources of variability need to be addressed nationally to ensure there is consistent, quality care available for all patients.     

Methodology for a six-state survey of primary care nurse practitioners

BackgroundPrimary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations.PurposeIn this paper, we report the methods of the largest survey of primary care NPs to date.MethodsTo overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments.FindingsWhile we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty.DiscussionIn future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.     

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.     

End-of-life care in the pediatric intensive care unit: attitudes and practices of pediatric critical care physicians and nurses

OBJECTIVE: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN: Cross-sectional survey. SETTING: A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.