Do HIV Care Outcomes Differ by Provider Type?

BACKGROUND: We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. SETTING: United States. METHODS: We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. RESULTS: Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). CONCLUSION: Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.

InCISE: Instrument for Comprehensive Incisional and Surgical Evaluation.

OBJECTIVE: The evaluation of healing after head and neck surgery is currently qualitative and non-standardized, limiting the quality of surgical healing assessments in clinical and research settings. We sought to develop an objective, standardized wound assessment score, and hypothesize that a reliable instrument can be developed to evaluate head and neck surgical wounds. METHODS: A prospective cohort study was conducted in a tertiary-care, academic head and neck surgery practice. Patients undergoing head and neck surgery were enrolled. A digital photograph protocol was developed for evaluating healing surgical wounds. A panel of experts developed and refined a wound healing score and established reliability, reproducibility, internal consistency, and validity of the score. RESULTS: InCISE: Instrument for comprehensive incisional and surgical evaluation was created. The utility of our wound healing score was assessed using classical test theory. We performed the major steps of establishing reliability in head and neck surgeons: (1) internal consistency (Cronbach's α = 0.81), (2) inter-observer reliability (intra-class correlation = 0.76), and (3) intra-rater reliability (intra-class correlation = 0.87), and content validity (through focus groups). Our composite measure was found to have strong internal consistency, inter-rater reliability, and intra-rater reliability. Preliminary work suggests criterion validity via associations with physical health related quality of life (SF-12). CONCLUSION: A wound healing score for head and neck surgery, InCISE, has been developed and is reliable, reproducible, and consistent. Although content validity is present and criterion validity is suggested, work continues to establish validity in this instrument to allow for expanded clinical and research use. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2166-2173, 2023.

Comparing Physician Assistant and Nurse Practitioner Practice in U.S. Emergency Departments, 2010-2017.

INTRODUCTION: We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). METHODS: We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. RESULTS: Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/-3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/-2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014-2016 and found that PA/NP visits share many of the same characteristics. CONCLUSION: While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.

Characterization of Biopsies by Dermatologists and Nonphysician Providers in the Medicare Population: A Rapidly Changing Landscape.

BACKGROUND: Previous studies show that nonphysician providers may require a higher number of biopsies to identify skin malignancies than dermatologists. Therefore, understanding the trends behind the types of providers performing biopsies may help analyze their impact on this vulnerable population. OBJECTIVE: This retrospective study analyzes changes in nationwide, regional, and state-level data on the number and proportion of biopsies performed by dermatologists compared with nonphysician providers. MATERIALS AND METHODS: Biopsy cases were isolated in the Medicare database from 2012 to 2018 using the HCPCS codes 11,100 and 11,101. Cases were limited to biopsies performed by a dermatologist, nurse practitioner (NP), or physician assistant (PA). RESULTS: From 2012 to 2018, national biopsy rates per 100,000 Medicare beneficiaries for dermatologists decreased by 6%, whereas those for NPs and PAs increased by 97% and 82%, respectively. Each state showed variation in both the proportion of biopsies by provider type and the net change in biopsies rates over time. All states saw increases in the number of biopsies per 100,000 Medicare beneficiaries by nonphysician providers. CONCLUSION: As the number of Medicare beneficiaries continues to grow, nonphysician providers are performing an increasing proportion of biopsies, with specific states and regions being affected more than others.

Modernizing the PA and NP workforce: Lessons learned from the COVID-19 pandemic.

ABSTRACT: The COVID-19 pandemic has been exceptionally disruptive to healthcare delivery, exposing the strengths and weaknesses of our healthcare system. Though systems will continue to improvise in the short term to provide essential patient care, thoughtful consideration should be given to a long-term approach to improve healthcare delivery. Policy makers, legislators, and healthcare system leaders have the opportunity to reflect on lessons learned during this time and update outdated and detrimental restrictions affecting healthcare providers who have been vital to the pandemic response. This article focuses on lessons learned about the use of physician assistants and NPs, who have been readily deployed during this time.

Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care.

BACKGROUND: Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models. OBJECTIVES: We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs. RESEARCH DESIGN: Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes. MEASURES: The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay. RESULTS: The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay. CONCLUSIONS: Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.

Midlevel Injectable Practice Patterns in Dermatology and Plastic Surgery Offices.

BACKGROUND: There is limited knowledge on the extent physicians delegate cosmetic procedures to midlevel providers. OBJECTIVE: To assess dermatology and plastic surgery practice patterns for the injections of neurotoxins and dermal fillers. MATERIALS AND METHODS: Four hundred ninety-two dermatology and plastic surgery practices were identified from 10 major US metropolitan areas. These practices were contacted, and staff were asked a series of questions to best characterize the practice patterns in regard to who performs the injectables in the office. RESULTS: Although most dermatology and plastic surgery practices had physicians as the only provider who gives injectables, 18.35% of dermatology and 25.4% of plastic surgery practices had nurse practioners and physician assistants giving injectables both with and without oversight of the supervising physician onsite. CONCLUSION: In a large majority of both plastic surgery and dermatology practices, physicians exclusively perform injections of neurotoxins and fillers. For practices that allow midlevel providers to perform injectables, the level of physician supervision is variable. In a small percentage of plastic surgery practices, surveyed midlevel providers exclusively performed injectables.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018.

Importance: Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented. Objective: To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs. Design, Setting, and Participants: This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021. Exposures: Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US). Main Outcomes and Measures: Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights. Results: Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%). Conclusions and Relevance: The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.

Exploring the impact of a decision support algorithm to improve clinicians' chemotherapy-induced peripheral neuropathy assessment and management practices: a two-phase, longitudinal study.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) negatively affects physical function and chemotherapy dosing, yet, clinicians infrequently document CIPN assessment and/or adhere to evidence-based CIPN management in practice. The primary aims of this two-phase, pre-posttest study were to explore the impact of a CIPN clinician decision support algorithm on clinicians' frequency of CIPN assessment documentation and adherence to evidence-based management. METHODS: One hundred sixty-two patients receiving neurotoxic chemotherapy (e.g., taxanes, platinums, or bortezomib) answered patient-reported outcome measures on CIPN severity and interference prior to three clinic visits at breast, gastrointestinal, or multiple myeloma outpatient clinics (n = 81 usual care phase [UCP], n = 81 algorithm phase [AP]). During the AP, study staff delivered a copy of the CIPN assessment and management algorithm to clinicians (N = 53) prior to each clinic visit. Changes in clinicians' CIPN assessment documentation (i.e., index of numbness, tingling, and/or CIPN pain documentation) and adherence to evidence-based management at the third clinic visit were compared between the AP and UCP using Pearson's chi-squared test. RESULTS: Clinicians' frequency of adherence to evidence-based CIPN management was higher in the AP (29/52 [56%]) than the UCP (20/46 [43%]), but the change was not statistically significant (p = 0.31). There were no improvements in clinicians' CIPN assessment frequency during the AP (assessment index = 0.5440) in comparison to during the UCP (assessment index = 0.6468). CONCLUSIONS: Implementation of a clinician-decision support algorithm did not significantly improve clinicians' CIPN assessment documentation or adherence to evidence-based management. Further research is needed to develop theory-based implementation interventions to bolster the frequency of CIPN assessment and use of evidence-based management strategies in practice. TRIAL REGISTRATION: ClinicalTrials.Gov, NCT03514680 . Registered 21 April 2018.

Primary Care's Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic recovery will require a broad and coordinated effort for infection testing, immunity determination, and vaccination. With the advent of several COVID-19 vaccines, the dissemination and delivery of COVID-19 immunization across the nation is of concern. Previous immunization delivery patterns may reveal important components of a comprehensive and sustainable effort to immunize everyone in the nation. METHODS: The delivery of vaccinations were enumerated by provider type using 2017 Medicare Part B Fee-For-Service data and the 2013-2017 Medical Expenditure Panel Survey. The delivery of these services was examined at the service, physician, and visit level. RESULTS: In 2017 Medicare Part B Fee-For-Service, primary care physicians provided the largest share of services for vaccinations (46%), followed closely by mass immunizers (45%), then nurse practitioners/physician assistants (NP/PAs) (5%). The Medical Expenditure Panel Survey showed that primary care physicians provided most clinical visits for vaccination (54% of all visits). CONCLUSIONS: Primary care physicians have played a crucial role in delivery of vaccinations to the US population, including the elderly, between 2012-2017. These findings indicate primary care practices may be a crucial element of vaccine counseling and delivery in the upcoming COVID-19 recovery and immunization efforts in the United States.

The changing landscape of nephrology physician assistants and nurse practitioners.

BACKGROUND: Physician assistants (PAs) and nurse practitioners (NPs) have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased. PURPOSE: To evaluate workforce patterns of PAs and NPs working in nephrology over the past decade. METHODS: Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade. RESULTS: Surveys of nephrology practitioners show the evolution of the dialysis-centralized practitioner to one encompassing all aspects of nephrology: hospital, intensive care unit, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities. IMPLICATIONS FOR PRACTICE: Physician assistants and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.

Physician assistant utilization in U.S. emergency departments; 2010 to 2017.

BACKGROUND: Physician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010-2017. METHODS: A retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS: Between 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25-44 years old (yo) (32.9%, ±6.2%) and 15-24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%). CONCLUSIONS: From 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.

Perceptions of Role Transition into Practice among Advanced Practice Providers and Physicians.

This study sought to examine the experiences of advanced practice providers (APPs) as an approach to inform the development of formalized programs for transition into practice and to compare APP (N = 122) and physician (N = 84) perceptions of the novice practitioners' acclimation into a provider role within the first year of practice. Using a cross-sectional survey design, two separate web-based questionnaires were distributed to APPs and physicians. The APPs' perspectives echoed findings of earlier studies with regard to perceived confidence, feelings of anxiety/fear, and inadequacy. In 16 of 23 paired items, physicians and APPs had similar perspectives about confidence/competence after orientation. Significant differences in their perceptions included amount of physician support, time management, length of time to become a fully functional APP, and independence. Better understanding of the perceptions of APPs and physicians can augment APP preparation for a shifting workforce composition and team-based, interprofessional practice designed to meet the population's health care needs.

Advanced Practice Providers Utilization Trends in Otolaryngology From 2012 to 2017 in the Medicare Population.

OBJECTIVE: Nurse practitioners and physician assistants form a growing advanced practice provider (APP) group. We aim to analyze the trends and types of services provided by APPs in otolaryngology. STUDY DESIGN: Cross-sectional study. SETTING: Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files, 2012-2017. METHODS: The Medicare database was searched for 13 commonly used otolaryngology-specific Current Procedural Terminology (CPT) codes, and 10 evaluation and management (E/M) codes were evaluated by provider type. Changes in code utilization were compared between physicians and APPs over time. RESULTS: From 2012 to 2017, there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in physician providers. APPs increased their share of new and established patient visits from 4% to 7%d 11% to 15%, respectively. There was not a significant difference over time in number of patient visits performed annually per provider according to provider type. The increase in number of APP vs physician providers was significantly greater for every procedure except for balloon sinus dilation and tympanostomy tube placement. CONCLUSION: Due to increasing numbers, APPs are accounting for more patient visits and procedures over time. The physician workforce and the numbers of procedures performed per physician have remained relatively stable from 2012 to 2017. Increasing complexity of patients seen and a broader range of procedures offered by work-experienced or postgraduate-trained APPs may further improve access to health care in the face of possible physician shortages.

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States.

BACKGROUND: Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS: Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION: Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

The role of PAs in providing mental health care.

The prevalence of psychiatric and substance use disorders in the United States is rising and of growing concern. Because such behavioral conditions are widespread, one approach is to collaborate with various medical professionals to help offset this demand. To address this issue, the frequency and types of mental health conditions encountered by physician assistants (PAs) were assessed. The National Commission on the Certification of Physician Assistants Practice Analysis was examined for the types of mental health conditions encountered across the spectrum of medical and surgical practices. The findings reveal that, in 2015, at least 62% of PAs saw and evaluated mental health conditions and behavioral disorders at least weekly in their settings. These patient diagnoses were seen with variability based on the specialty of the PA. The highest percentage of cases reported by PAs were in psychiatry, followed by general internal medicine, emergency medicine, family medicine, and hospital medicine. With the profession projected to grow, recruiting, retaining, and integrating more PAs into mental health care is a suggested strategy for addressing national provider shortages.

A global census of physician assistants and physician associates.

The physician assistant or physician associate (PA) profession is being adopted in many countries. At a time of improved communication and international exchange of educational methods, no central repository of PA numbers exists. The authors set out to consolidate basic information on PAs. The purpose of the project was to support efforts underway that include the global development of PAs. The prevalence of PAs in each country was obtained using an informant methodology strategy and supplemented with reports and internet validation. Eighteen countries have a PA (similar healthcare professionals with different titles were not included), for an estimated total of more than 132,000 clinically active PAs and 366 training programs. In most countries, PA expansion was reported as being underway.