Toward identification and intervention to address financial toxicity and unmet health-related social needs among adolescents and emerging adults with cancer and their caregivers: A cross-cultural perspective.

PURPOSE: We qualitatively explored the unique needs and preferences for financial toxicity screening and interventions to address financial toxicity among adolescents and emerging adults (younger AYAs: 15-25 years) with cancer and their caregivers. METHODS: We recruited English- or Spanish-speaking younger AYAs who were treated for cancer within the past 2 years and their caregivers. Semi-structured interviews were conducted to explore preferences for screening and interventional study development to address financial toxicity. The data were coded using conventional content analysis. Codes were reviewed with the study team, and interviews continued until saturation was reached; codes were consolidated into categories and themes during consensus discussions. RESULTS: We interviewed 17 participants; nine were younger AYAs. Seven of the 17 preferred to speak Spanish. We identified three cross-cutting themes: burden, support, and routine, consistent, and clear. The burden came in the form of unexpected costs such as transportation to appointments, as well as emotional burdens such as AYAs worrying about how much their family sacrificed for their care or caregivers worrying about the AYA's physical and financial future. Support, in the form of familial, community, healthcare institution, and insurance, was critical to mitigating the effects of financial toxicity in this population. Participants emphasized the importance of meeting individual financial needs by routinely and consistently asking about financial factors and providing clear guidance to navigate these needs. CONCLUSION: Younger AYAs and their caregivers experience significant financial challenges and unmet health-related social needs during cancer treatment and often rely on key supports to alleviate these unmet needs. When developing interventions to mitigate financial toxicity, clinicians and health systems should prioritize clear, consistent, and tailorable approaches to support younger AYA cancer survivors and their families.

Racial and ethnic disparities in ED use among older adults with asthma and primary care nurse practitioner work environments.

Background: Nurse practitioners (NPs) increasingly deliver primary care in the United States. Yet, poor working conditions strain NP care. We examined whether racial/ethnic health disparities in ED visits among older adults with asthma are moderated by primary care NP work environments. Methods: Survey data on NP work environments in six states were collected from 1,244 NPs in 2018-2019. 2018 Medicare claims data from 46,658 patients with asthma was merged with survey data to assess the associations of all-cause and ambulatory care sensitive conditions (ACSC) ED visits with NP work environment and race/ethnicity using logistic regression. Results: NP work environment moderated the association of race (Black patients versus White patients) with all-cause (odds ratio [OR]: 0.91; p-value = 0.045) and ACSC (OR: 0.90; p-value = 0.033) ED visits. Conclusions: Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with favorable NP work environments.

Facilitators and Barriers to Pediatric Nurse Practitioner Practice in the United States: A Systematic Review.

INTRODUCTION: The pediatric nurse practitioner (PNP) workforce was designed to improve child health equity. We aimed to systematically review the evidence on facilitators and barriers to PNP practice. METHOD: We included empirical studies on PNP practice in the United States and excluded studies with non-identifiable PNP data. We applied Joanna Briggs Institute tools to appraise studies and applied critical interpretive synthesis principles to synthesize. RESULTS: The final sample is 26 studies, mostly published before 2013 and observational. Prescriptive privileges, training program availability, organizational climate, and telehealth are facilitators. Mandated physician supervision, reduced pediatric curricula, geographically disparate training programs, and poor data infrastructure are barriers. The sample is limited by a moderate to high risk of bias. DISCUSSION: Evidence suggests modifiable factors impact PNP practice and could have important implications for child health equity. We offer a theoretical model to guide robust research studying the PNP workforce and health equity.

Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas.

INTRODUCTION: The prevalence of substance use disorders (SUDs) is growing among older adults, and older adults in rural areas face disparities in access to SUD care. Rural older adults with SUDs commonly have comorbid chronic conditions that puts them at risk for frequent acute healthcare utilization. In rural areas, primary care for patients with SUDs are increasingly provided by nurse practitioners (NPs), and quality primary care services may decrease ED visits in this population. Yet, NP-delivered primary care for rural older adults with SUDs may be limited by work environment barriers, which include lack of support, autonomy, and visibility. This study assessed the relationship between the NP work environment and ED utilization among rural older adults with SUDs. METHODS: This was a secondary analysis of cross-sectional data from a large survey of NPs in six U.S. states merged with Medicare claims. The study measured the NP work environment by the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which measure 1) independent practice and support, 2) NP-physician relations, 3) NP-administration, and 4) professional visibility. Multilevel logistic regression models, adjusted for practice and patient covariates, assess the relationship between the NP work environment and all-cause ED use. RESULTS: The sample included 1152 older adults with SUDs who received care at 126 rural NP primary care practices. NP independent practice and support at the practice was associated with 49 % lower odds of all-cause ED visits among older adults with SUDs. There were no relationships between the other NP-PCOCQ subscales and all-cause ED visits. CONCLUSIONS: Organizational support for NP independent practice is associated with lower odds of all-cause ED utilization among rural older adults with SUDs. Practice administrators should ensure that NPs have access to support and resources to enhance their ability to care for rural older adults with SUDs. Ultimately, these practice changes could reduce ED utilization and health disparities in this population.

DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions.

BACKGROUND: Many professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes. PURPOSE: To examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs. METHODS: We use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship. RESULS: We find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs. DISCUSSION: These findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes. CONCLUSIONS: Further empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.