Nurse practitioners' degrees and associations with time use, functional autonomy, and job outcomes.

BACKGROUND: Doctorate of Nursing Practice preparation is recommended for entry to nurse practitioner (NP) practice but there are few comparative studies, and their designs conflate educational pathways. PURPOSE: To investigate time use, functional autonomy, and job outcomes among NPs without a doctorate, NPs whose initial NP preparation and doctorate were separated by 2 or more years, and NPs whose NP preparation and doctorate were concurrent. METHOD: We selected all NPs from the 2018 National Sample Survey of Registered Nurses, except those whose doctorates focused on research. We controlled for confounding and applied sample weights to produce nationally representative results. DISCUSSION: NPs' educational pathways are associated with distinct practice roles and, moving forward, policy should be informed by evidence that accounts for their differences. CONCLUSION: Concurrent NPs had higher levels of functional autonomy compared with NPs without a doctorate, but patterns of time use were essentially the same. Separate doctoral education was associated with teaching and administration.

The Orthopaedic NP Workforce: Results From a Nationally Representative Survey.

Although a growing number of nurse practitioners (NPs) are practicing in orthopaedics, little is known about the workforce. The aim of this study was to estimate the size of the orthopaedic NP workforce, compare it with the workforce of primary care NPs, and investigate the interaction effect specialty NP practice and physician relationships have on NP role perception. We selected licensed, practicing orthopaedic and primary care NPs from the 2018 National Sample Survey of Registered Nurses and compared demographics, education, experience, functional autonomy, and job outcomes. Nationally, 2,796 NPs described their specialty as orthopaedics. Compared with primary care NPs, they spent 27% more time on care coordination, were half as likely to have their own patient panel, and were most likely to say that their NP education was fully utilized when in a collaborative relationship with physicians. Differences between orthopaedic and primary care NPs may call for reform of Consensus Model that currently places specialty practice outside its regulatory network.

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis.

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

Certification alignment of nurse practitioners in acute care.

BACKGROUND: The Consensus Model specifies distinct education preparations for acute care and primary care nurse practitioners (NP), but incomplete implementation and employer hiring practices risk misalignment of certification and practice. PURPOSE: Report the prevalence of acute care certification among NPs working in acute care, investigate the factors associated with alignment, and explore the impact of alignment on nurse outcomes. METHODS: Using the 2018 National Sample Survey of Registered Nurses, we selected NPs practicing acute care and compared employment, education, and nurse outcomes by certification alignment. FINDINGS: A minority of NPs (44.5%) held acute care certification. Controlling for NP characteristics, those practicing in states that restrict a NP's practice to their area of certification had 47% higher odds of acute care certification. DISCUSSION: Understanding patterns of alignment in the NP workforce and the factors that produce them is critical to an appropriate regulatory framework for advanced practice nursing.

Opioid Prescribing by Nurse Practitioners in Medicare Part D: Impact of State Scope of Practice Legislation.

Many state legislatures restrict nurse practitioner (NP) scope of practice as a way of addressing patient safety concerns. The purpose of this study was to investigate the influence of state NP scope of practice laws on the prescription of oxycodone and hydrocodone containing medications by NP and MD/DO/PA prescribers to Medicare Part D beneficiaries. Using the Medicare Part D public use file, we analyzed oxycodone and hydrocodone containing prescriptions per Medicare Part D beneficiary by prescriber type, NP state scope of practice, and geographic variables. Our results demonstrate that the state scope of practice variable had the same effect, in identical direction and significance, on NP opioid prescribing patterns as it had on MD/DO/PA prescribers, a group to whom NP scope of practice laws do not apply. Thus, scope of practice in this study was not an exclusive predictor of NP practice and prescribing.

Sexual and reproductive health content in nurse practitioner transition to practice training programs.

OBJECTIVE: To describe the sexual and reproductive health (SRH) offerings of transition to practice training programs for certified primary care nurse practitioners in the United States. STUDY DESIGN: Program Directors from all identified primary care training programs (n = 51) were invited to participate in an online survey to assess the SRH didactic and clinical offerings based on competencies developed by the World Health Organization and adapted for the US across 15 domains and 15 related procedures. RESULTS: Twenty-two (43%) surveys were completed. There was considerable variation in offerings, with no single domain required by all programs, nor any program requiring trainees to complete didactic and clinical offerings in all domains. On average, programs required didactic and clinical training for approximately a third of the competencies in the Reproductive Tract Cancers domain (the most required domain) and for approximately a quarter of the competencies in the Contraceptive domain. Infertility/Fertility and Environmental Risks to Reproductive Health were the least commonly required domains. Clinical training tended to be more frequently required or offered than didactic instruction in almost all domains.Regarding procedures, both didactic and clinical training on insertion and removal of intrauterine devices were required by one third of programs. No-scalpel vasectomy was the procedure in which programs were least likely to offer trainees either didactic or clinical training, followed by uterine aspiration for missed or elective abortion or heavy menstrual bleeding. CONCLUSION: Although SRH is recognized as an essential component of primary care, its inclusion in transition to practice primary care training programs for NPs is low and inconsistent. IMPLICATIONS STATEMENT: Preparing primary care NPs to deliver competent SRH care is important for workforce development and patient care. Our study highlights a need for additional research to determine the baseline competency in SRH care among primary care NPs in order to further enhance education, training and policies with this aim.

90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies.

Medication adherence is the "Plus" in the global challenge to have 90% of HIV-infected individuals tested, 90% of those who are HIV positive treated, and 90% of those treated achieve an undetectable viral load. The latter indicates viral suppression, the goal for clinicians treating people living with HIV (PLWH). The comparative importance of different psychosocial scales in predicting the level of antiretroviral adherence, however, has been little studied. Using data from a cross-sectional study of medication adherence with an international convenience sample of 1811 PLWH, we categorized respondent medication adherence as None (0%), Low (1-60%), Moderate (61-94%), and High (95-100%) adherence based on self-report. The survey contained 13 psychosocial scales/indices, all of which were correlated with one another (p < 0.05 or less) and had differing degrees of association with the levels of adherence. Controlling for the influence of race, gender, education, and ability to pay for care, all scales/indices were associated with adherence, with the exception of Berger's perceived stigma scale. Using forward selection stepwise regression, we found that adherence self-efficacy, depression, stressful life events, and perceived stigma were significant predictors of medication adherence. Among the demographic variables entered into the model, nonwhite race was associated with double the odds of being in the None rather than in the High adherence category, suggesting these individuals may require additional support. In addition, asking about self-efficacy, depression, stigma, and stressful life events also will be beneficial in identifying patients requiring greater adherence support. This support is essential to medication adherence, the Plus to 90-90-90.

Regulation of Certified Nurse-Midwife Scope of Practice: Change in the Professional Practice Index, 2000 to 2015.

INTRODUCTION: Certified nurse-midwives (CNMs) across the United States are educated in the same core competencies, yet scope of practice varies with state regulation. The Health Resources and Services Administration (HRSA) funded studies published in 1994 and 2004 on the professional practice environment of CNMs, nurse practitioners, and physician assistants, and developed the Certified Nurse-Midwife Professional Practice Index (CNMPPI), a 100-point scoring system of state regulation focusing on 3 domains: legal status, reimbursement, and prescriptive authority. The purpose of this study was to examine changes to CNM regulation between 2000 and 2015 by updating scores to the CNMPPI. METHODS: Individual state CNMPPI scores from 2000 were updated for every year through 2015 by reviewing data published in the American College of Nurse-Midwives (ACNM) quarterly publication Quickening, the annual advanced practice registered nurse legislative updates in the journal Nurse Practitioner, and the ACNM State Legislative and Regulatory Guidance. RESULTS: Mean state scores increased 18%, from 69.7 in 2000 to 79.8 in 2015, and variation between state scores fell. Increases were seen in all 3 domains, with the greatest increase in the domain of prescriptive authority and the smallest in the legal domain. Individual state CNMPPI scores tend to be correlated with scores of adjacent states. DISCUSSION: The CNMPPI can be used to document changes in practice authority of CNMs. The increase in state CNMPPI scores and decrease in variance across states can be interpreted as indicating growth of professional authority and increasing consensus regarding the CNM role. The scoring system needs to be updated to reflect the current health systems environment and to include certified midwives and other midwives meeting the International Confederation of Midwives definition of a midwife. Applications of the CNMPPI to future research are discussed.

Enhancing quality of primary care using an ambulatory ICU to achieve a patient- centered medical home.

RESEARCH OBJECTIVE: The Patient-Centered Medical Home (PCMH) has been advocated as a model to address the lack of coordination and continuity in the health system. However, implementation in practice has been slow and incompletely described. STUDY DESIGN: Patients referred into the program received intensive nurse follow-up focused on medication adherence, care coordination, and education. Patients graduate from the program when treatment goals are met. POPULATION STUDIED: The first 100 patients enrolled into the PCMH focused program of a primary care clinic in an urban, academic medical center. The main outcome measures are goal adherence and emergency room use. PRINCIPAL FINDINGS: Ninety percent of enrollees met the health goals set for them at enrollment. During their enrollment, 31.6% of patients with diabetes reduced and maintained their blood glucose readings; 24.6% of patients with hypertension reduced and maintained their blood pressure readings. Emergency department use in the time period following enrollment dropped 46.7%. CONCLUSIONS: The ambulatory intensive care unit program showed an improvement in health outcomes and health care use.This program also helps to move the practice toward PCMH by centralizing care through a primary care provider, enhancing access to care, and by focusing on the patient holistically through rapport with a nurse. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: This care delivery method drives the clinic closer to the PCMH and toward the Accountable Care Organization (ACO) model.

Identification and treatment of mental and substance use conditions: health plans strategies.

BACKGROUND: Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment. OBJECTIVES: The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies. METHODS: In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total). MEASURES: We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population. RESULTS: Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies. CONCLUSIONS: Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.

Health plan requirements for mental health and substance use screening in primary care.

BACKGROUND: Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it. OBJECTIVES: We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners. DESIGN: In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements. PARTICIPANTS: Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region. MEASUREMENTS: We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems. RESULTS: By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening. CONCLUSIONS: Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment.

The need to bleed: women's attitudes and beliefs about menstrual suppression.

PURPOSE: To describe how women feel about monthly menstruation in general and menstrual suppression in particular. DATA SOURCES: This descriptive, exploratory study used a convenience sample of 221 women who completed a self-administered questionnaire on attitudes toward monthly menstruation and menstrual suppression. Descriptive statistics and correlations were used to analyze the data. CONCLUSIONS: Women not using oral contraceptives (OCs) had more menstrual symptoms than women using OCs. Negative feelings about menstruation were correlated with interest in menstrual suppression. Over two thirds expressed interest in reducing menstrual pain and the amount of menstrual discharge, particularly if not taking OCs. Women who were not interested in changing their menstrual pattern said they would be anxious about not having a menstrual flow and said it would not be normal. IMPLICATIONS FOR PRACTICE: Advanced practice nurses play an important role in educating women about menstrual health. Clinicians can use this information to assess women's attitudes and beliefs about menstrual symptoms and to educate them about misconceptions. The FDA approved Seasonale in September 2003, the first dedicated OC created to reduce the number of menstrual cycles yearly. Women need to be educated about the pros and cons of suppression; some women will benefit from suppression, and others will consider it unnatural.