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1.
BMJ Open Qual ; 12(2)2023 06.
Article in English | MEDLINE | ID: mdl-37311623

ABSTRACT

BACKGROUND: Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity. OBJECTIVE: To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes. DESIGN: Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA. PARTICIPANTS: Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017. OUTCOME: Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017. RESULTS: Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL. CONCLUSIONS: A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.


Subject(s)
Diabetes Mellitus , Adult , Humans , Cohort Studies , Glycated Hemoglobin , Diabetes Mellitus/therapy , Ambulatory Care Facilities , Primary Health Care
2.
JAAPA ; 36(1): 32-40, 2023 Jan 01.
Article in English | MEDLINE | ID: mdl-36484712

ABSTRACT

ABSTRACT: Efforts to improve access to high-quality, efficient primary care have highlighted the need for team-based care. Most primary care teams are designed to maintain continuity of care between patients and primary care providers (PCPs), because continuity of care can improve some patient outcomes. However, PCPs are interdependent because they care for, or share, patients. PCP interdependence, and its association with continuity of care, is not well described. This study describes a measure of PCP interdependence. We also evaluate the association between patient and panel characteristics, including PCP interdependence. Our results found that the extent of interdependence between PCPs in the same clinic varies widely. A range of patient and panel characteristics affect continuity of care, including patient complexity and PCP interdependence. These results suggest that continuity of care for complex patients is sensitive to panel characteristics, including PCP interdependence and panel size. This information can be used by primary care organizations for evidence-based team design.


Subject(s)
Continuity of Patient Care , Primary Health Care , Humans , Primary Health Care/methods , Quality of Health Care , Ambulatory Care Facilities
3.
JAAPA ; 35(2): 1-10, 2022 Feb 01.
Article in English | MEDLINE | ID: mdl-34985006

ABSTRACT

OBJECTIVE: Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks. METHODS: This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis. RESULTS: Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits. CONCLUSIONS: Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.


Subject(s)
Electronic Health Records , Primary Health Care , Health Personnel , Humans , Patient Care Team , Quality of Health Care , Surveys and Questionnaires
4.
Med Care ; 58(8): 681-688, 2020 08.
Article in English | MEDLINE | ID: mdl-32265355

ABSTRACT

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.


Subject(s)
Diabetes Mellitus/economics , Health Personnel/economics , Patient Acceptance of Health Care/statistics & numerical data , Primary Health Care/economics , Adult , Aged , Aged, 80 and over , Cohort Studies , Diabetes Mellitus/psychology , Female , Health Personnel/standards , Health Personnel/statistics & numerical data , Humans , Male , Middle Aged , Nurse Practitioners/economics , Nurse Practitioners/standards , Nurse Practitioners/statistics & numerical data , Physician Assistants/economics , Physician Assistants/standards , Physician Assistants/statistics & numerical data , Physicians/economics , Physicians/standards , Physicians/statistics & numerical data , Primary Health Care/methods , Primary Health Care/statistics & numerical data , United States , United States Department of Veterans Affairs/economics , United States Department of Veterans Affairs/organization & administration , United States Department of Veterans Affairs/statistics & numerical data
6.
Health Aff (Millwood) ; 38(6): 1028-1036, 2019 06.
Article in English | MEDLINE | ID: mdl-31158006

ABSTRACT

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.


Subject(s)
Chronic Disease/therapy , Health Expenditures/statistics & numerical data , Nurse Practitioners/economics , Patient Acceptance of Health Care/statistics & numerical data , Physician Assistants/economics , Physicians/economics , Aged , Diabetes Mellitus/economics , Humans , Nurse Practitioners/statistics & numerical data , Physician Assistants/statistics & numerical data , Physicians/statistics & numerical data , Primary Health Care , United States , United States Department of Veterans Affairs
7.
Ann Intern Med ; 169(12): 825-835, 2018 12 18.
Article in English | MEDLINE | ID: mdl-30458506

ABSTRACT

Background: Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. Objective: To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). Design: Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. Setting: 568 VA primary care facilities. Patients: 368 481 adult patients with diabetes treated pharmaceutically. Measurements: The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. Results: The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. Limitation: Most VA patients are men who receive treatment in a staff-model health care system. Conclusion: No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. Primary Funding Source: VA Health Services Research and Development.


Subject(s)
Diabetes Mellitus, Type 2/therapy , Nurse Practitioners , Physician Assistants , Physicians, Primary Care , Primary Health Care/methods , Adult , Aged , Aged, 80 and over , Blood Pressure/physiology , Cholesterol, LDL/blood , Diabetes Mellitus, Type 2/blood , Diabetes Mellitus, Type 2/physiopathology , Female , Glycated Hemoglobin/metabolism , Humans , Male , Middle Aged , Physicians, Primary Care/supply & distribution , Primary Health Care/standards , Retrospective Studies , Treatment Outcome
8.
Hum Resour Health ; 10: 42, 2012 Nov 13.
Article in English | MEDLINE | ID: mdl-23148792

ABSTRACT

BACKGROUND: Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA) has been a frontrunner in the use of nurse practitioners (NPs) and physician assistants (PAs). Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians. METHODS: This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician). RESULTS: NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits. CONCLUSIONS: This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.

9.
Support Care Cancer ; 19(1): 155-9, 2011 Jan.
Article in English | MEDLINE | ID: mdl-20820814

ABSTRACT

PURPOSE: Patients with advanced cancer often experience negative emotion; clinicians' empathic responses can alleviate patient distress. Much is known about how physicians respond to patient emotion; less is known about non-physician clinicians. Given that oncology care is increasingly provided by an interdisciplinary team, it is important to know more about how patients with advanced cancer express emotions to non-physician clinicians (NPCs) and how NPCs respond to those empathic opportunities. METHOD: We audio recorded conversations between non-physician clinicians and patients with advanced cancer. We analyzed 45 conversations between patients and oncology physician assistants, nurse practitioners, and nurse clinicians in which patients or their loved ones expressed at least one negative emotion to the NPC (i.e., an empathic opportunity). Empathic opportunities were coded three ways: type of emotion (anger, sadness, or fear), severity of emotion (least, moderate, or most severe), and NPC response to emotion (not empathic, on-topic medical response, and empathic response). RESULTS: We identified 103 empathic opportunities presented to 25 different NPCs during 45 visits. Approximately half of the empathic opportunities contained anger (53%), followed by sadness (25%) and fear (21%). The majority of emotions expressed were moderately severe (73%), followed by most severe (16%), and least severe (12%). The severity of emotions presented was not found to be statistically different between types of NPCs. NPCs responded to empathic opportunities with empathic statements 30% of the time. Additionally, 40% of the time, NPCs responded to empathic opportunities with on-topic, medical explanations and 30% of the responses were not empathic. CONCLUSION: Patients expressed emotional concerns to NPCs typically in the form of anger; most emotions were moderately severe, with no statistical differences among types of NPC. On average, NPCs responded to patient emotion with empathic language only 30% of the time. A better understanding of NPC-patient interactions can contribute to improved communication training for NPCs and, ultimately, to higher quality patient care in cancer.


Subject(s)
Attitude of Health Personnel , Empathy , Neoplasms/psychology , Professional-Patient Relations , Anger , Emotions , Fear , Female , Humans , Male , Tape Recording
10.
J Physician Assist Educ ; 21(3): 13-7, 2010.
Article in English | MEDLINE | ID: mdl-21141405

ABSTRACT

PURPOSE: Although research shows that empathic communication improves patient outcomes, physicians often fail to respond empathically to patients. Nurses and physician assistants (PAs) may be able to help fill the need for empathic communication. Our study compares the attitudes of oncologists, nurses, and PAs toward communication with patients who demonstrate negative emotions. METHODS: We analyzed surveys from 48 oncologists, 26 PAs, and 22 nurses who participated in the Studying Communication in Oncologist-Patient Encounters trial. Surveys included previously validated items that examined attitudes toward communication with patients about emotion. RESULTS: The mean age of oncology physicians was higher (49 years) than that of PAs (40 years) or nurses (43 years), and 19% of physicians, 81% of PAs, and 100% of nurses were female. Race, years of oncology experience, and previous communication training were similar across provider types. Most nurses (82%) and PAs (68%) described themselves as having a socioemotional orientation, while most oncologists (70%) reported a technological/scientific orientation (p < .0001). PAs and nurses indicated more comfort with psychosocial talk than did oncologists (p < .0001). Discomfort with disclosing uncertainty and provider confidence and expectations when addressing patient concerns were similar across provider types. CONCLUSIONS: PAs and nurses were more oriented toward socioemotional aspects of medicine and were more comfortable with psychosocial talk than were oncologists. Future studies should examine whether these differences are attributable to other factors, including gender, and whether nurses and PAs are more likely than physicians to demonstrate empathic behaviors when patients express negative emotions.


Subject(s)
Attitude of Health Personnel , Emotions , Medical Oncology , Negativism , Nurses/psychology , Physician Assistants/psychology , Physicians/psychology , Professional-Patient Relations , Adult , Female , Health Care Surveys , Humans , Male , Middle Aged
11.
Health Aff (Millwood) ; 29(5): 887-92, 2010 May.
Article in English | MEDLINE | ID: mdl-20439876

ABSTRACT

Although the physician assistant (PA) profession was created to bolster the primary care workforce, PAs have assumed increasing roles in subspecialties. This paper compares specialty prevalence between physicians and physician assistants, analyzes trends in PAs' specialty choices from 1997 to 2006, and suggests options for influencing these specialty choices in the future. The number of PAs is growing more rapidly in surgical and medical subspecialties than in primary care. Salaries loosely correlate with specialty choice, especially among specialties with the highest income. If there is a societal interest in encouraging PAs to practice in primary care, new economic or educational policies may be required.


Subject(s)
Career Choice , Medicine/trends , Physician Assistants/trends , Primary Health Care , Salaries and Fringe Benefits/trends , United States , Workforce
12.
Health Serv Res ; 43(5 Pt 2): 1906-22, 2008 Oct.
Article in English | MEDLINE | ID: mdl-18665857

ABSTRACT

OBJECTIVE: To investigate whether the use of physician assistants (PAs) as providers for a substantive portion of a patient's office-based visits affects office visit resource use. DATA SOURCE: Medical Expenditure Panel Survey (MEPS) Household Component data from 1996 to 2004. STUDY DESIGN: This retrospective cohort study compares the number of office-based visits per year between adults for whom PAs provided >or=30 percent of visits and adults cared for by physicians only. DATA COLLECTION/EXTRACTION METHODS: The Agency for Healthcare Research and Quality collects MEPS data using methods designed to produce data representative of the U.S. noninstitutionalized civilian population. Negative binomial regression was used to compare the number of visits per year between persons with and without PA care, adjusted for demographic, geographic, and socioeconomic factors; insurance status; health status; and medical conditions. PRINCIPAL FINDINGS: After case-mix adjustment, patients for whom PAs provided a substantive portion of care used about 16 percent fewer office-based visits per year than patients cared for by physicians only. This difference in the use of office-based visits was not offset by increased office visit resource use in other settings. CONCLUSIONS: Results indicate that the inclusion of PAs in the U.S. provider mix does not affect overall office visit resource use.


Subject(s)
Health Services Needs and Demand/statistics & numerical data , Health Workforce , Office Visits/statistics & numerical data , Physician Assistants/statistics & numerical data , Physicians/statistics & numerical data , Specialization , Acute Disease/epidemiology , Adult , Chronic Disease/epidemiology , Cohort Studies , Diagnosis-Related Groups/classification , Episode of Care , Family Characteristics , Female , Health Expenditures/statistics & numerical data , Health Services Research , Humans , Incidence , Male , Medicine/statistics & numerical data , Middle Aged , Physicians/classification , Retrospective Studies , Risk Adjustment , United States/epidemiology
13.
Health Serv Res ; 42(5): 2022-37, 2007 Oct.
Article in English | MEDLINE | ID: mdl-17850531

ABSTRACT

OBJECTIVE: To assess applicability of national health survey data for generalizable research on outpatient care by physician assistants (PAs) and nurse practitioners (NPs). DATA SOURCES: Methodology descriptions and 2003 data files from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the Medical Expenditure Panel Survey, and the Community Tracking Study. STUDY DESIGN: Surveys were assessed for utility for research on PA and NP patient care, with respect to survey coverage, structure, content, generalizability to the U.S. population, and validity. National estimates of patient encounters, statistically adjusted for survey design and nonresponse, were compared across surveys. DATA COLLECTION/EXTRACTION METHODS: Surveys were identified through literature review, selected according to inclusion criteria, and analyzed based on methodology descriptions. Quantitative analyses used publicly available data downloaded from survey websites. PRINCIPAL FINDINGS: Surveys varied with respect to applicability to PA and NP care. Features limiting applicability included (1) sampling schemes that inconsistently capture nonphysician practice, (2) inaccurate identification of provider type, and (3) data structure that does not support analysis of team practice. CONCLUSIONS: Researchers using national health care surveys to analyze PA and NP patient interactions should account for design features that may differentially affect nonphysician data. Workforce research that includes NPs and PAs is needed for national planning efforts, and this research will require improved survey methodologies.


Subject(s)
Ambulatory Care , Health Care Surveys , Nurse Practitioners , Physician Assistants , Humans , Research Design , Review Literature as Topic , United States
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