Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients

Strengthening health care overall is essential to the health of our nation and promoting access to health care as well as controlling health care costs in a quality cost-effective manner. Nurse practitioners have demonstrated to be effective and cost-effective providers in prior research; however, many states restrict their practice. We examined for a statistically significant relationship between the level of advanced practice registered nurse (APRN) practice (full, reduced, or restricted) allowed and results of recent nationwide, state level analyses of Medicare or Medicare-Medicaid beneficiaries of potentially avoidable hospitalizations, readmission rates after inpatient rehabilitation, and nursing home resident hospitalizations and then compared them with state health outcome rankings. States with full practice of nurse practitioners have lower hospitalization rates in all examined groups and improved health outcomes in their communities. Results indicate that obstacles to full scope of APRN practice have the potential to negatively impact our nation's health. Action should be taken to remove barriers to APRN practice.     

Educational strategies to enhance placement and retention of nurse practitioners in rural Arkansas

PURPOSE: To examine the factors and incentives enhancing nurse practitioners' (NPs') long-term employment in rural areas. DATA SOURCE: The participants were 121 master's prepared or higher educated NPs located in rural Arkansas. A survey about role preparation and employment factors was mailed to the participants. CONCLUSIONS: We found that 10% of all respondents were not currently employed in the role of an NP. The majority of rural-employed NPs had didactic content focusing on rural-practice opportunities and engaged in rural practicums while in graduate school. Rural NPs were much more likely to have graduated from research-intensive universities. Nearly 90% of NPs reported they were somewhat to very well prepared for practice in rural Arkansas. IMPLICATIONS FOR EDUCATION: The shortage of health care providers remains one of the most irresolvable problems in the U.S. health care delivery system. Compounding the shortage is the unequal distribution of health care practitioners in rural areas. Evidence indicates that NP students engaged in rural clinical practicums were more likely to practice in rural areas. In light of this information, nurse educators should expand the NP educational process beyond rurally located practicums to deliver the entire educational process to the NP students' rural homes.     

Differences in test ordering between nurse practitioners and attending emergency physicians when acting as Provider in Triage

Study objectives

To compare diagnostic test ordering practices of NPs with those of physicians in the role of Provider in Triage (PIT).

Organizational influences on the use of low-value care in primary health care – a qualitative interview study with physicians in Sweden

AimThe aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC.DesignQualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis.SettingSix publicly owned primary health care centers in Stockholm.SubjectsThe participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7.Main outcome measuresCategories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC.ResultsFour types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient–physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. .ConclusionThe influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.

KEY POINTS

• We know little about how organizational factors influence the use of low-value care (LVC) in primary health care.
• Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.
• This study provides insights about how these factors influence LVC use.
• Strategies at multiple levels of the health-care system may be warranted to reduce LVC.

     

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.     

Realist evaluation of privately practising nurse practitioners in Australia: Development and refinement of theories

Background

Nurse practitioners (NPs) have been practising in Australia since 2001, predominantly in the public sector. To facilitate the expansion of NPs working in community and primary health care settings, legislative changes in 2010 led to privately practising NPs (PPNPs) being eligible to provide care subsidised through the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). To date, there has been little evaluation of PPNP services in Australia. Reported in this paper is the process through which national survey data enabled the refinement and development of theories on PPNP services in Australia.

疼痛规范强化培训对改善护士的癌痛相关知识和态度的影响

目的 探讨疼痛规范化强化培训对护士癌痛知识和态度的影响.方法 该院所有护士纳入培训及调查人群.入组对象在1年内接受以医院、科室或片区为单位的癌痛规范化培训,内容包括癌痛知识、用药规范、不良反应处理、患者教育等.采用疼痛相关知识及态度量表(Knowledge and Attitudes Survey Regarding Pain)作为调查工具,在培训前后收集调查量表.从调查样本中随机选取各50例进行统计分析比较.结果 共168例研究对象纳入培训人群,培训前后分别发放量表各168份,分别有效回收141份和132份,随机各抽取50份.与培训前比较,培训后癌痛知识和态度的合格率由50%提高至86%(χ2=14.89,P<0.001),癌痛药物的正确使用方法掌握度由10%提高至62%(χ2=29.34,P<0.001),常见不良反应的观察和处理则无明显变化(88%∶76%,χ2=2.43,P=0.118),26%的护士可应用癌痛相关量表对患者进行教育和评估(26%∶6%,χ2=7.44,P=0.006).结论 疼痛规范化培训可改善护士的癌痛相关知识和态度.     

The role of nurse practitioners in hospital settings: implications for interprofessional practice

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how ‘embedding’ the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.     

Contributions of prognostic factors for poor outcome in primary care low back pain patients

Background: Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone. Aims: To determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors. Methods: Prospective cohort study of back pain patients (30–59 years) at five general practices in Staffordshire, UK (n =389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear‐avoidance; self‐rated health) were assessed for their association with disabling and limiting pain after 12‐months. The proportion of those with persistent problems whose outcome was related to each factor was calculated. Results: Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment (adjusted relative risk (RR) 4.2; 95% CI 2.0, 8.5) and high pain intensity (4.1; 1.7, 9.9). The largest proportions of persistent problems were related to high pain intensity (68%; 95% CI 27, 87%) and unemployment (64%; 33, 82%). Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self‐rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems. Conclusions: Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub‐groups for intervention.     

The accuracy of paediatric limb radiograph interpretation by nurse practitioners in a single centre

BackgroundNurse practitioners (NP) are an integral part of the urgent and emergency care workforce in the United Kingdom providing safe and effective care. Despite this, there is limited research assessing the ability of NPs to correctly interpret isolated paediatric limb injury radiographs in the urgent and emergency care environment.AimThe aim of this study was to compare the accuracy in interpreting isolated paediatric limb radiographs between NPs and consultant radiologists.SettingA nurse-led urgent care centre (UCC) in central London, United Kingdom.Participants296 paediatric patients with isolated limb injuries who had a radiograph requested and interpreted by an NP.MethodsThirteen NPs (adult registered) with various backgrounds and qualifications participated in this prospective, single-centre healthcare analysis. Review of all clinical presentations at the UCC over a 3-month period (September–November 2017) identified 296 paediatric patients (aged 2–15) who received a peripheral limb radiograph. Clinical records for each patient were analysed to document demographics, mechanism of injury, NP examination findings, radiographic interpretation and formal radiologist report. NP interpretation of each radiograph was classified as definite fracture, possible fracture or no fracture. This was compared to the final radiologist report (considered the gold standard) to calculate the sensitivity and specificity of NP radiograph interpretation.ResultsNPs reported a total of 94 radiographs (32%) as definite fracture, 176 (59%) as no fracture and 26 (9%) as possible fracture, as compared to radiologists at 71 (24%), 218 (74%) and 7 (2%). A total of 242 (82%) of radiographs were correctly identified by NPs, while 54 (18%) were incorrectly interpreted. The sensitivity of the NP limb radiographic interpretation was 92%, with a specificity of 78%.ConclusionsThe findings validate the clinical and diagnostic skills of NPs in the interpretation of isolated paediatric limb radiographs.     

Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings

In psychological health treatment studies it has been shown that differences between therapists account for some of the non‐specific effect of treatment but this phenomenon has not so far systematically been investigated in musculoskeletal disorders. In this study we evaluated and compared the size and potential influence of the ‘practitioner effect’ (or ‘therapist effect’) in three randomised treatment trials of low back pain and neck pain patients in primary care. We calculated the proportion of variance in outcomes attributable to differences across practitioners, i.e. the practitioner–variance partition coefficient (p–vpc). As measures of outcome, we focused on self‐reported disability as the primary outcome, but we also investigated assessed psychological outcomes. The p–vpc for the disability measures ranged from 2.6% to 7.1% across trials and time points (post treatment and follow up). Estimates differed between treatment subgroups within trials; being highest in treatment subgroups assigned to psychosocial‐based interventions. A ‘practitioner effect’ does exist and is more pronounced in treatments involving greater psychosocial emphasis. This has implications for both practice and research in this clinical area. It highlights the importance of patient–practitioner interactions, and the need to address practitioner effects in designing and analysing outcome studies in low back pain and neck pain in primary care.     

A comparison in independent nurse prescribing and patient group directions by nurse practitioners in the emergency department: A cross sectional review

AimTo explore nurse prescribing in an emergency department using patient group directions versus independent nurse prescribing.BackgroundPatient group directions allow restricted access to medication in unselected patients using pre-set criteria. Independent nurse prescribing is a flexible method of medication provision. Limited data exists on the application of either method in clinical practice.MethodsExploration of patient group directions and independent nurse prescribing application in an emergency department using 617 nurse practitioners’ clinical notes; 235 and 382 respectively. Patient attendances from 01/07/2009 to 30/06/2010 were randomly sampled. Prescribing frequency; range of medications and diagnoses; independent episode completion and prescribing safety was explored.ResultsStatistical difference exists in prescribing frequency between the independent nurse prescribers (51.6%, n = 197) and patient group directions (32.3%, n = 76). Appropriate medication given by 99.7% (n = 381) of independent nurse prescribers, with 1 contraindicated drug provided. The limitations of patient group directions was highlighted in 11.8% (n = 9) of cases, however all drugs given were appropriate for the diagnosis. No statistical difference in independent episode completion.ConclusionsNurses provide appropriate medication in an emergency department. Patients being managed by nurse prescribers were more likely to receive medication. Further investigation is required to justify this.     

Care received by patients from nurse practitioners and physicians in U.S. primary care settings

PurposeNurse practitioners (NPs) and physicians serve in both usual source of care (USC) and supplement roles to each other in the provision of primary care to patients. Yet little is known about the care that patients receive from providers in these roles. This study examined the care individuals received when NPs and physicians served in USC and supplemental roles.MethodsPooled data from the Household Component of the Medical Expenditure Panel Survey 2002-2013. Cross-sectional, secondary data analysis using propensity score matching and multinomial logistic regression. Data were collected from a national subsample of households.FindingsRegardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians. Patients reported having similar diagnoses when seen by NPs and physicians serving in USC roles, but different diagnoses when NPs and physicians served in supplemental roles.DiscussionNPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians.