The aim of this study was to answer the overall question: Does primary care diabetes management for Medicare patients differ in scope and outcomes by provider type (physician or nurse practitioner)?
To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians.
Medicare part A and part B claims during 2012-2013.
Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening.
Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians.
Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening.
The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.
Key Points Regarding NP Practice in Alberta:
The aim of this study was to answer the overall question: Does primary care diabetes management for Medicare patients differ in scope and outcomes by provider type (physician or nurse practitioner)?
In the USA as well as globally, there is a pressing need to address high healthcare costs while improving healthcare outcomes. Primary health care is one area where healthcare reform has received considerable attention, in part because of continued projections of primary care physician shortages. Many argue that nurse practitioners are one solution to ease the consequences of the projected shortage of primary care physicians in the USA as well as other developed countries.
Cross-sectional quantitative analysis of 2012 Medicare claims data.
A 5% Standard Analytic File of 2012 Medicare claims data for beneficiaries with Type 2 diabetes were analysed. A medical productivity index was used to stratify patients as healthiest and least healthy who were seen by either nurse practitioners only or primary care physicians exclusively. Included in the analyses were health services utilization, health outcomes and healthcare cost variables.
The patients in the nurse practitioner only group, overall and stratified by medical productivity index status, had significantly improved outcomes compared with all primary care physician provider groups regarding healthcare services utilization, patient health outcomes and healthcare costs.
These findings inform current healthcare workforce conversations regarding healthcare quality, outcomes and costs. Our results suggest nurse practitioner engagement in chronic care patient management in primary care settings is associated with lower cost and better quality health care.
Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitionerservice in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.
This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.
The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.
There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.
To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home.
As demand for long-term care increases, alternative care models including nurse practitioners are being explored.
Cost-effectiveness analysis using a controlled before-after design.
The study included an 18-month ‘before’ period (2005–2006) and a 21-month ‘after’ time period (2007–2009). Data were abstracted from charts from 2008–2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves.
Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%.
Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.
The pressure in out-of-hours primary care is high due to an increasing demand for care and rising health-care costs. During the daytime, substituting general practitioners (GPs) with nurse practitioners (NPs) shows positive results to contribute to these challenges. However, there is a lack of knowledge about the impact during out-of-hours. The current study aims to provide an insight into the impact of substitution on resource use, production and direct health-care costs during out-of-hours.
At a general practitioner cooperative (GPC) in the south-east of the Netherlands, experimental teams with four GPs and one NP were compared with control teams with five GPs. In a secondary analysis, GP care versus NP care was also examined. During a 15-month period all patients visiting the GPC on weekend days were included. The primary outcome was resource use including X-rays, drug prescriptions and referrals to the Emergency Department (ED). We used logistic regression to adjust for potential confounders. Secondary outcomes were production per hour and direct health-care costs using a cost-minimization analysis.
We analysed 6,040 patients in the experimental team (NPs: 987, GPs: 5,053) and 6,052 patients in the control team. There were no significant differences in outcomes between the teams. In the secondary analysis, in the experimental team NP care was associated with fewer drug prescriptions (NPs 37.1 %, GPs 43 %, p < .001) and fewer referrals to the ED (NPs 5.1 %, GPs 11.3 %, p = .001) than GP care. The mean production per hour was 3.0 consultations for GPs and 2.4 consultations for NPs (p < .001). The cost of a consultation with an NP was €3.34 less than a consultation with a GP (p = .02).
These results indicated no overall differences between the teams. Nonetheless, a comparison of type of provider showed that NP care resulted in lower resource use and cost savings than GP care.
To find the optimal balance between GPs and NPs in out-of-hours primary care, more research is needed on the impact of increasing the ratio of NPs in a team with GPs on resource use and health-care costs.
KINGSTON, R.I., July 18, 2017 —Hospitalization rates plummeted 61 percent, and emergency room visits fell 64 percent among a group of patients who received home visits from nurse practitioners and graduate students during a six-month period in 2016, according to a University of Rhode Island College of Nursing study.
Purpose: This Gadamerian hermeneutic study was undertaken to understand
the meaning of autonomy as interpreted by nurse practitioners (NPs) through
their lived experiences of everyday practice in primary health care.
Data sources: A purposive sample of nine NPs practicing in primary health
care was used. Network sampling achieved a broad swath of primary care NPs
and practice settings. Data were collected by face-to-face interviews. Because NP
autonomy is concerned with gender and marginalization, Gilligan’s feminist perspective
was utilized during interpretive analysis.
Conclusions: Having Genuine NP Practice was the major theme, reflecting the
participants’ overall meaning of their autonomy. Practicing alone with the patient
provided the context within which participants shaped the meaning of Having
Genuine NP Practice. Having Genuine NP Practice had four subthemes: relationships,
self-reliance, self-empowerment, and defending the NP role.
Implications for practice: The understanding of Having Genuine NP Practice
will enable NPs to articulate their autonomy clearly and better influence
healthcare reform. Implications for advanced practice nursing education include
integrating findings into classroom discussion to prompt self-reflection of what
autonomy means and socialization to the NP role.
The period of transition from registered nurse to nurse practitioner is often challenging. While adjusting to their autonomous role, nurse practitioners need to create and define a distinct role for themselves within practice contexts that may be unfamiliar, sometimes unwelcoming and inhospitable. During this time of transition, nurses need well developed negotiation skills and personal attributes including resilience, tenacity, fortitude and determination.
The purpose of the research reported in this paper was to explore the transition experiences of 10 newly endorsed nurse practitioners in Australia during their first year of practice. This paper focuses on power, control and political manoeuvring that negatively impacted the ׳nurse practitioners׳ transition. A qualitative approach using a modified version of Carspecken׳s five stage critical ethnography, informed by focused ethnography, was the methodology selected for this study. Methods included observations of practice, journaling, face to face and phone interviews which were recorded, transcribed and analysed thematically.
“The enemy within” emerged as a dominant theme highlighting issues of power, powerlessness and politics dominating the participant׳s experiences. Power struggles amongst nurses, both overt and covert, and the deliberate misuse of power were frequently encountered. Many of the participants felt powerless and ill-prepared to negotiate the challenging situations in which they found themselves. Many lacked the skills needed to address the negative behaviours they experienced.
This paper reports on the experiences of 10 newly endorsed nurse practitioners during their transition to the nurse practitioner role. The impact of the political climate at the time of this study had an undeniable influence on many of the participants׳ transition experiences. Competition for the limited numbers of designated nurse practitioner positions led to hostility between senior nurses and, in some contexts, a jostling for power, control, prestige and position. Rather than camaraderie, cooperation and collaboration, many of the participants described feeling besieged, undermined and alienated. The new nurse practitioners felt isolated, unwelcomed and unsupported. Several felt burnt out and abandoned their aspirations to be become a nurse practitioner. They left and returned to practice as a registered nurse.
In Canada, health care reform is underway to address escalating costs, access and quality of care issues, and existing personnel shortages in various health disciplines. One response of the nursing profession to these stimuli has been the development of the advanced practice nurse, namely, the nurse practitioner (NP). NPs are in an excellent position to address current shortcomings through increasing points of access to the health care system, providing an emphasis on education and disease prevention, and delivering high-quality, cost-effective care in a multitude of practice settings. With an emphasis on the social determinants of health, NPs are in a prime position to provide care to underserved and vulnerable populations across Canada. Despite the potential for NPs to be instrumental in health care reform, there is a lack of support and regulation necessary for their optimal use. Barriers to mobilizing NPs in Canada exist and impede the integration of NPs into the Canadian health care system, which has both quality of care and social justice implications.
Contandriopoulos, D., Brousselle, A., Breton, M., Sangster-Gormley, E., Kilpatrick, K., Dubois, C. A., … & Perroux, M. (2016). Nurse practitioners, canaries in the mine of primary care reform. Health Policy.
A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of “disruptive innovations” to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners’ potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners’ place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.
Peeters, M. J., van Zuilen, A. D., van den Brand, J. A., Bots, M. L., van Buren, M., ten Dam, M. A., … & van de Ven, P. J. (2014). Nurse practitioner care improves renal outcome in patients with CKD. Journal of the American Society of Nephrology, 25(2), 390-398.
Treatment goals for patients with CKD are often unrealized for many reasons, but support by nurse practitioners may improve risk factor levels in these patients. Here, we analyzed renal endpoints of the Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study after extended follow-up to determine whether strict implementation of current CKD guidelines through the aid of nurse practitioners improves renal outcome. In total, 788 patients with moderate to severe CKD were randomized to receive nurse practitioner support added to physician care (intervention group) or physician care alone (control group). Median follow-up was 5.7 years. Renal outcome was a secondary endpoint of the MASTERPLAN study. We used a composite renal endpoint of death, ESRD, and 50% increase in serum creatinine. Event rates were compared with adjustment for baseline serum creatinine concentration and changes in estimated GFR were determined. During the randomized phase, there were small but significant differences between the groups in BP, proteinuria, LDL cholesterol, and use of aspirin, statins, active vitamin D, and antihypertensive medications, in favor of the intervention group. The intervention reduced the incidence of the composite renal endpoint by 20% (hazard ratio, 0.80; 95% confidence interval, 0.66 to 0.98; P=0.03). In the intervention group, the decrease in estimated GFR was 0.45 ml/min per 1.73 m2 per year less than in the control group (P=0.01). In conclusion, additional support by nurse practitioners attenuated the decline of kidney function and improved renal outcome in patients with CKD.
Allen, J. K., Himmelfarb, C. R. D., Szanton, S. L., & Frick, K. D. (2014). Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. The Journal of cardiovascular nursing, 29(4), 308.
Findings: Comprehensive management of cardiovascular risk factors by NP/CHW teams that includes lifestyle counseling, drug prescription and titration and promotion of compliance is a cost-effective strategy to reduce cardiovascular risk and thereby address health disparities in underserved, minority populations. Chronic illness care in medically underserved patients with CVD or at high risk for CVD is complex. These data add to the body of evidence that specially trained nurse-led teams are efficacious strategies to improve management. A sizeable body of research reinforces that patient care outcomes are similar and sometimes better when patients are managed by NP’s as primary care providers as compared to physicians. As the costs of health care for chronic diseases continues to increase, NPs are in pivotal positions to address the need for safe, effective, patient-centered, efficient, and equitable health care.
Stanik-Hutt, J., Newhouse, R. P., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., … & Weiner, J. P. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8), 492-500.
Evidence regarding the impact of nurse practitioners (NPs) compared to physicians (MDs) on health care quality, safety, and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990-2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs (or teams without NPs) are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs.
Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., … & DiCenso, A. (2015). Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. BMJ open, 5(6), e007167.
Objective To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care.
Design A systematic review of randomised controlled trials reported since 1980.
Data sources 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites.
Included studies Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes.
Results 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly.
Conclusions Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.
Conclusion: Existing studies suggest that granting Pennsylvania’s nurse practitioners Full Practice Authority could potentially benefit Pennsylvanians by increasing access to comparable or better health care at lower costs. Research demonstrates reform would save Pennsylvanians at least $6.4 billion in the next ten years, increase the number of NPs statewide by 13%, and improve the statewide quality of primary care.
The practical implication is that we have a high degree of confidence that the impacts of less restrictive regulation of APRNs will be at least as large as described in the lower-bound estimates in this report. We have provided our rationale for why it is appropriate to view the entire increase in APRN utilization resulting from less restrictive regulation as being financed through an injection of external federal funds. Hence, the EIA assessment provided in Section III is a valid means of assessing the impact of that supply increase on the North Carolina economy. Thus, less restrictive regulation of APRNs should result in new jobs (at least 4,053 but possibly as many as 7,507), more payroll (from $257 to 476 million) and higher taxes (from $21.8 to 40.3 million). An expanded supply of APRNs would make impressive progress toward alleviating the anticipated shortage of physicians in 2020, and in the best case holds the promise of entirely eradicating the shortages of primary care physicians, OB/GYNs and anesthesiologists. North Carolinians would enjoy better access to care of equivalent or better quality even as the system shed some unnecessary costs in the process. It is rare that a health policy change is capable of generating such positive gains across all these dimensions.
Journal of Nursing Scholarship: June 2017
The purpose of this study was to add to what is known about patient satisfaction with nurse practitioner(NP) care, from the perspective of breast cancer patients who were followed by an NP.
This study utilized Interpretive Description, a qualitative method aimed at making sense of the experiential aspects of health care and developing practical knowledge for improved care. Nine patients receiving NP-led care in an outpatient breast cancer clinic were interviewed about their perspectives on and experiences with NP-led care. Interview transcripts were thematically analyzed.
The NP role has long been regarded as a way of addressing many contemporary health system problems, although there continue to be barriers to the effective utilization of the role, including public and patient misunderstandings. This study revealed that, despite persistent traditional role understandings about health professionals, the patient participants appreciated the benefits of NP care and were highly satisfied with both the physical care and holistic support they received during the course of their treatment.
Today’s healthcare system is characterized by accessibility issues, unmet patient need, workforce issues, and funding pressures. This research supports and enriches what is known about the benefits and usefulness of NP-provided care from the viewpoint of those receiving the care. The findings offer guidance to NPs in the clinical setting regarding patient needs and optimal care strategies.
To compare acute hospital length of stay and cost-savings for patients with hip fracture before and after commencement of the Orthopaedic Nurse Practitioner and identify variables that increase length of stay in hospital.
Globally, hip fractures are associated with significant morbidity and mortality. Whilst the practical benefits of the Orthopaedic Nurse Practitioner have been anecdotally shown, an analysis showing the cost-saving benefits has yet to be published.
A retrospective cohort study.
Data from two population-based cohorts (2010, 2013) of hip fracture patients aged ≥65 years were extracted from the electronic hospital database at a large Western Australian tertiary metropolitan hospital. Multivariate linear regression was used to model factors affecting length of stay in hospital. A simple economic analysis was undertaken and cost-savings were estimated.
For comparison (n = 354) and intervention (n = 301) groups, average age was 84 years and over 70% were female. Analyses showed length of stay was shorter in 2013 compared with 2010 (4.4-5.3 days). Shorter length of stay was associated with type of procedure and surgery within 24-hr and longer length of stay was associated with co-morbid conditions of pulmonary disease, congestive heart failure, dementia, anaemia on admission and complications of delirium, urinary tract infection, myocardial infarction and pneumonia. The cost-savings to the hospital over one year was $354,483 and the net annual cost-savings per patient was $1,178.
Implementation of the Orthopaedic Nurse Practitioner role for care of hip fracture patients can reduce acute hospital length of stay resulting in important cost-savings.