Differences in the Patterns of Care Between Emergency Department Visits with and Without a Physician.

BACKGROUND: A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician. OBJECTIVES: We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician. METHODS: We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician. RESULTS: Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2). CONCLUSIONS: A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants.

BACKGROUND: Physicians see most emergency department (ED) patients, but, recently, nurse practitioners (NPs) and physician assistants (PAs) have provided an increasing amount of ED care. PURPOSE: Compare NP and PA teams' practice patterns to physician teams in EDs. METHODS: Using 12 years of data from the National Hospital Ambulatory Medical Care Survey (2009-2020), we used multivariate regression analysis to separately examine the associations between the ED practice patterns (i.e., number of diagnostic services, number of procedures, waiting time, boarding time, length of visit, and hospital admission) of patients seen by NP or PA teams compared with physician teams. DISCUSSION: Patient visits to NP and PA teams received fewer diagnostic services and procedures, had shorter visits, and were less likely to be hospitalized. CONCLUSION: If the additional diagnostic services, procedures, and hospital admission provided by physician teams were unnecessary for the patients studied, NP and PA team care could be more efficient.

How Are Patients Who Legally Use Medical Marijuana Treated When Hospitalized?

The majority of U.S. states have legalized marijuana for medical use and some states have legalized marijuana for recreational use; yet, marijuana remains illegal federally. Given the misalignment between state and federal policies, this paper seeks to explore how hospitals handle inpatients' medical marijuana use in states where medical marijuana is legal. To examine this phenomenon, we conducted an anonymous, online, cross-sectional survey of nurse leaders working in acute care inpatient settings in states that had legalized medical marijuana. Using descriptive statistics, we report on these nurse leaders' experiences. There were 811 survey responses-291 who worked in an acute care inpatient setting in a state that had legalized medical marijuana. Among those respondents, only a small percentage reported that inpatients had some access to their medical marijuana: 5.8% reported that the drug was kept in the pharmacy and dispensed like other prescriptions; another 3.4% indicated that patients kept the medical marijuana in their rooms and took it, as needed. Most respondents (55.6%) reported that patients were switched to an alternative medication during their inpatient hospital stays. Almost half (49.4%) of the nurse leaders who reported that alternative medications were used, reported that opioids were substituted, and the majority reported that the marijuana was safer than the opioids. These findings are concerning given the increase in opioid overdose deaths.

Is Adversity in Childhood Linked to Marijuana Use in Adulthood?: Findings from the Behavioral Risk Factor Surveillance System.

Background: Adverse childhood experiences (ACEs) are potentially traumatic events, which can have long-term, negative consequences. Few studies have examined ACEs' relationship to marijuana use. Objectives: We examined the association between ACEs and past-month marijuana use among adults and the pathways between childhood adversity and marijuana use. Methods: Adults from five states (n = 22,991) who responded to the 2019 Behavioral Risk Factors Surveillance System were included. We examined the prevalence of ACEs and marijuana use. We employed generalized structural equation modeling to assess the relationship between ACEs and marijuana use and the role of depression and poor mental and physical health as possible mediators. Results: Overall, 65.0% of the population reported 1+ ACE. Heavy marijuana use and past-month marijuana use prevalence rates were 10.3% and 5.0%, respectively. We found mediation effects for depression and poor mental health but not poor physical health. The number of ACEs was associated with a statistically significant increase in any past-month marijuana use-indirect effects ranged from 1.0 (95% CI, 1.0-1.0) to 1.4 (95% CI, 1.2-1.7), direct effects ranged from 1.1 (95% CI, 07-1.7) to 5.3 (95% CI 3.2-8.8), and total effects ranged from 1.1 (95% CI, 0.7-1.7) to 5.9 (95% CI, 3.6-9.8). Women, married persons, and middle aged and older adults had a lower odds of marijuana use. Reporting at least one HIV risk behavior was associated with an increased odds of marijuana use. Conclusion: ACE exposure was positively associated with marijuana use. Depression and poor mental health separately mediated this relationship.

A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers.

BACKGROUND: Under the Affordable Care Act, the number and capacity of community health centers (HCs) is growing. Although the majority of HC care is provided by primary care physicians (PCMDs), a growing proportion is delivered by nurse practitioners (NPs) and physician assistants (PAs); yet, little is known about how these clinicians' care compares in this setting. OBJECTIVES: To compare the quality of care and practice patterns of NPs, PAs, and PCMDs in HCs. RESEARCH DESIGN: Using 5 years of data (2006-2010) from the HC subsample of the National Ambulatory Medical Care Survey and multivariate regression analysis, we estimated the impact of receiving NP-delivered or PA-delivered care versus PCMD-delivered care. We used design-based and model-based inference and weighted all estimates. SUBJECTS: Primary analyses included 23,704 patient visits to 1139 practitioners-a sample representing approximately 30 million patient visits to HCs in the United States. MEASURES: We examined 9 patient-level outcomes: 3 quality indicators, 4 service utilization measures, and 2 referral pattern measures. RESULTS: On 7 of the 9 outcomes studied, no statistically significant differences were detected in NP or PA care compared with PCMD care. On the remaining outcomes, visits to NPs were more likely to receive recommended smoking cessation counseling and more health education/counseling services than visits to PCMDs (P≤0.05). Visits to PAs also received more health education/counseling services than visits to PCMDs (P≤0.01; design-based model only). CONCLUSIONS: Across the outcomes studied, results suggest that NP and PA care were largely comparable to PCMD care in HCs.

Working under a clinic-level quality incentive: primary care clinicians' perceptions.

BACKGROUND: A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level. METHODS: This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives. RESULTS: Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance. CONCLUSION: The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

An Assessment of State-Led Reform of Long-Term Services and Supports.

Health care in the United States is fragmented, inefficient, and rife with quality concerns. These shortcomings have particularly serious implications for adults with disabilities and functionally impaired older adults in need of long-term services and supports (LTSS). Three strategies have been commonly pursued by state governments to improve LTSS: expanding noninstitutional care, integrating payment and care delivery, and realigning incentives through market-based reforms. These strategies were analyzed using an evaluation framework consisting of the following dimensions: ease of access; choice of setting/provider; quality of care/life; support for family caregivers; effective transitions among multiple providers and across settings; reductions in racial/ethnic disparities; cost-effectiveness; political feasibility; and implementability. Although the analysis highlights potential benefits and drawbacks associated with each strategy, the limited breadth of the evidentiary base precludes an assessment of impact across all nine dimensions. More importantly, the analysis exposes the interdependent, complex system of care within which LTSS is situated, suggesting that policy makers will require a holistic and long-term perspective to achieve needed changes. Addressing the nation's LTSS needs will require a multipronged strategy incorporating a range of health and social services to meet the complex care needs of a diverse population in a variety of settings.

Are Patients Who Trust Their Providers More Likely to Use Medical Cannabis?

Background: Trust is an essential element of the patient-provider relationship and has been associated with better patient outcomes; however, it is not clear what role trust might play in influencing patients' willingness to try medical cannabis when it is recommended in states where it has been legalized for medical use. Objectives: To explore the relationship between peoples' trust in their health care clinicians and hospitals and their willingness to consider using medical cannabis if it is recommended by their clinician or hospital. Methods: We conducted an anonymous, cross-sectional, online survey of adults who participated in the Qualtrics Research Company Panel and used quotas to match our sample to the characteristics of the U.S. population. Results: We received 1120 completed surveys. The vast majority of respondents (84.4%) reported having a regular provider and 42.5% of those who reported having a regular physician and nearly 35.6% of those who reported having another regular provider (e.g., nurse practitioner, physician assistant) reported that they "completely" trusted that clinician. Those who reported "completely" trusting their usual clinician were more than twice as likely to report they would definitely use medical cannabis if recommended (42.5% vs 20.6%). Similarly, the greater respondents' trust in hospitals, the more likely they were to report a willingness to consider using recommended medical cannabis. Conclusion: Patient trust in their health providers is related to patients' willingness to use recommended medical cannabis.

PhD program faculty: Preparing the next generation of nurse researchers.

This article explores approaches to strengthening research education in nursing doctoral (PhD) programs with a focus on the roles of interdisciplinary faculty and the National Institute of Nursing Research (NINR), 2022-2026 Strategic Plan. Our view is that these components are interrelated and essential in educating the next generation of nurse researchers. To explore these topics, we undertook two analyses: (1) an examination of the preparation of PhD directors across the 119 AACN member schools; and (2) an evaluation of NIH funding levels to schools of nursing and the principal investigators' backgrounds among NINR grantees. We found significant homogeneity in the backgrounds of PhD directors in schools of nursing and considerable NINR funding to non-nurse researchers on topics within the nursing discipline. To strengthen the research infrastructure of PhD programs and achieve the American Association of Colleges of Nursing's (AACN) vision for doctoral education, we suggest incorporating interdisciplinary faculty and greater utilization of the NINR Strategic Plan.

The impact of recreational cannabis laws on cannabis use disorder during "treat and release" visits to hospital emergency departments in four U.S. states, 2017-2020.

States' legalization of cannabis influences cannabis use and may increase cannabis use disorder (CUD)-a problematic pattern of use leading to significant impairment. Few studies have examined the influence of recreational cannabis legalization on CUD in the emergency department (ED). We used four years of data from the State Emergency Department Databases (SEDD) (2017-2020) from three states (CO, MD, OR) and three years of SEDD from Rhode Island (2017-2019) to examine the relationship between the recreational legalization of cannabis and CUD among "treat and release" ED visits. During the study period, CO and OR were legal for recreational cannabis while it was illegal in MD and RI. We examined the proportion of ED visits for CUD and used multivariate logistic regression to examine the association between recreational legalization and CUD diagnosis. The sample had 17,434,655 ED visits (56.2 % female). The proportion of ED visits for CUD was 0.63 %. Annual rates ranged from 0.67 % (2017) to 0.59 % (2019) and state-level rates were 0.39 % (CO), 0.35 % (OR), 1.03 % (MD), and 0.79 % (RI). Compared to ED visits in legal states, a higher proportion of ED visits in non-legal states were from women (56.8 % versus 55.7 %) and Blacks (40.9 % versus 5.9 %). Compared to states where recreational cannabis was illegal, legalizing cannabis for recreational use was associated with nearly a 50 % decrease in the adjusted odds of CUD (AOR = 0.49, 95 % CI 0.47, 0.52). In summary, CUD rates among "treat and release" ED visits were significantly lower in legalized states than in non-legal states.

Marijuana Use and Older Adults' Self-Reported Difficulty Concentrating, Remembering, or Making Decisions.

OBJECTIVE: This study investigated the relationship, in adults 50 years and older, between self-reported past-month marijuana use and difficulty concentrating, remembering, or making decisions (SDCRMD) because of a physical, mental, or emotional condition, using the Behavioral Risk Factor Surveillance System (BRFSS). METHOD: We relied on a sample of 294,000 adults (53.4% female), 50 years and older, from 21 U.S. states and two territories over 4 years (2016-2019). We conducted descriptive analyses to examine the prevalence of past-month marijuana use and SDCRMD and used multivariate logistic regression to examine the association between marijuana use and SDCRMD, controlling for demographic and health-related variables. RESULTS: The overall prevalence of SDCRMD was 11.0%, 95% confidence interval (CI) [10.6%, 11.5%], and the prevalence of self-reported past-month marijuana use was 7.1%, 95% CI [6.7%, 7.5%]. Of those reporting past-month marijuana use, 19.9%, 95% CI [17.8%, 22.1%] reported SDCRMD. Past-month marijuana users were 1.5, 95% CI [1.1, 2.1] times more likely to report SDCRMD than nonusers. Prevalence of past-month marijuana use was higher in states with legalization of both medical and recreational marijuana; however, prevalence of SDCRMD was not. CONCLUSIONS: We found a strong, positive, and statistically significant relationship between past-month marijuana use and SDCRMD. This finding serves as an important first step in identifying the relationship between older adults' self-reported marijuana use and their difficulty concentrating, remembering, and decision-making because of a physical, mental, or emotional condition; however, additional research is needed.

"We want what's best for patients." nurse leaders' attitudes about medical cannabis: A qualitative study.

Background: The majority of states have legalized medical cannabis. Nurse leaders must be prepared for an increase in patients' use of the drug across all care settings. Objectives: To explore nurse leaders' attitudes towards, knowledge of, and experiences with medical cannabis. Design: : Descriptive qualitative study design. Participants: 28 nurse leaders-19 in four focus groups of 3-7 participants and another 9 in interviews. Methods: Semi-structured, one-on-one interviews and focus groups of nurse leaders about their attitudes towards and experiences with patients' use of medical cannabis. Thematic analysis was used to identify themes and subthemes. Results: Four major themes were identified: overwhelming support for legalized medical cannabis; importance of overcoming the stereotype of a gateway drug; problematic mismatch between federal and state cannabis policies; and nursing needs to be move involved. Conclusions: There was strong support for legalized medical cannabis to meet patients' needs; yet, respondents reported little discussion about or education regarding medical cannabis among nurses. Inconsistent federal and state cannabis policies were viewed as especially problematic and in need of alignment.

Trends in Cannabis Polysubstance Use During Early Pregnancy Among Patients in a Large Health Care System in Northern California.

Importance: Rates of prenatal cannabis use are increasing alongside perceptions that cannabis is a harmless therapeutic for pregnancy-related ailments, while rates of prenatal use of alcohol and tobacco are decreasing. It is important to examine whether cannabis use during pregnancy is increasing similarly among patients with and patients without co-occurring substance use. Objectives: To examine trends in cannabis polysubstance use during pregnancy and to test differences in cannabis use over time among pregnant individuals who use only cannabis vs those who use cannabis and other substances. Design, Setting, and Participants: This cross-sectional time-series study used data from 367 138 pregnancies among 281 590 unique pregnant patients universally screened for prenatal substance use as part of standard care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2018. Statistical analysis was performed from October 5, 2021, to April 18, 2022. Exposures: Time (calendar year). Main Outcomes and Measures: Use of substances during early pregnancy was assessed via universal screening with a self-administered questionnaire (for cannabis, alcohol, stimulants, and nicotine) and/or positive results of a urine toxicology test (for cannabis, alcohol, stimulants, and pharmaceutical opioids), and data were extracted from the electronic health record. Results: The study sample of 367 138 pregnancies from 281 590 unique pregnant patients (median gestation at time of screening, 8.6 weeks [IQR, 7.3-10.6 weeks]) was 25.9% Asian or Pacific Islander, 6.6% Black, 25.8% Hispanic, 38.0% non-Hispanic White, and 3.6% other race or ethnicity; 1.1% were aged 11 to 17 years, 14.9% were aged 18 to 24 years, 61.9% were aged 25 to 34 years, and 22.1% were aged 35 years or older; and the median neighborhood household income was $70 455 (IQR, $51 563-$92 625). From 2009 to 2018, adjusted rates of use of only cannabis during pregnancy (no other substances) increased substantially from 2.39% (95% CI, 2.20%-2.58%) in 2009 to 6.30% (95% CI, 6.00%-6.60%) in 2018, increasing at an annual relative rate of 1.11 (95% CI, 1.10-1.12). The rate of use of cannabis and 1 other substance also increased (annual relative rate, 1.04 [95% CI, 1.03-1.05]), but not as rapidly (P < .001 for difference), while the rate of use of cannabis and 2 or more other substances decreased slightly (annual relative rate, 0.97 [95% CI, 0.96-0.99]). Adjusted rates of prenatal use of cannabis and alcohol (1.04 [95% CI, 1.03-1.06]) and cannabis and stimulants (1.03 [95% CI, 1.01-1.06]) increased over time, while rates of prenatal use of cannabis and nicotine (0.97 [95% CI, 0.96-0.98]) decreased. Conclusions and Relevance: In this cross-sectional time-series study, rates of prenatal cannabis use during early pregnancy increased significantly more rapidly among patients without co-occurring substance use, which could reflect increased acceptability of cannabis and decreased perceptions of cannabis-related harms. Furthermore, increased rates of use of cannabis with alcohol and stimulants warrant continued monitoring.

Do Teams Improve the Quality of Ambulatory Care?

Using data from the National Ambulatory Medical Care Survey, we examined team composition in office-based practices and compared their relative quality of care. We found that, compared with physician-only teams, patients seen by physician and nurse practitioner/nurse midwife teams and those seen by physician and nurse teams were more likely to receive statins for hyperlipidemia and blood pressure screening, respectively. We also found that patients seen by physician and physician assistant teams were less likely to receive recommended care for all 4 quality indicators, and patients seen by any interprofessional team were less likely to receive recommended depression treatment than physician-only teams.

Why do Americans use marijuana?

BACKGROUND: Marijuana is the most commonly used illicit drug in the United States; yet, little is known about why adults use it. We examined the prevalence of past-month marijuana use by users' reasons for use-medical, recreational, and both-and identified correlates of each group. METHODS: Data from 20 states, which participated in the 2017-2019 Behavioral Risk Factor Surveillance System and fielded the marijuana use module, and multinomial logistic regression analysis were used to identify risk factors for past-month marijuana use by reason for use. User profiles were developed to illustrate how states' policy environments influenced reported reasons for use. RESULTS: The average predicted probabilities of past-month marijuana use for medical, recreational, and both reasons were 28.6 %, 38.2 %, and 33.1 %, respectively. Age, gender, marital and employment status, income, mode and frequency of administration, and health status were associated with reasons for use. The reasons that young adult males who were infrequent marijuana users and binge drinkers gave for their marijuana use varied by state policy environment-in legal states, the average predicted probabilities were 5.3 % lower for recreational reasons and 5.0 % higher for both reasons. Reported reasons for past-month marijuana use did not significantly differ by state policy environment among daily users who were older women in poor mental and physical health. DISCUSSION: Significant differences existed in the characteristics of past-month marijuana users by reasons for use. Our estimates can serve as a baseline against which post-legalization marijuana users' reasons for use can be compared as state policy environments shift.

Prevalence and Correlates of HIV Testing among Sexual Minorities.

Objectives: We established baseline prevalence rates of HIV testing among adult, sexual minorities and identified the correlates of never being HIV tested. Methods: We used a 20-state sample of the 2017-2019 Behavioral Risk Factor Surveillance System to identify sexual minorities who responded to the HIV testing question (N=433,042). Using weighted multivariate logistic regression analysis, we identified the characteristics associated with never being HIV tested and the impact of state health departments' HIV testing messages on testing status. Results: Overall, 41.6% of sexual minorities reported never being HIV tested with statistically significant state-level variation. Being younger (18-24 years) or older (65+ years), not black, married, and in good health significantly increased the odds of never being HIV tested as did lacking regular healthcare access and reporting no high-risk HIV behaviors. States' HIV testing messages had no statistically significant effect on HIV testing status. Conclusions: Although sexual minorities were less likely than straight respondents to report never being HIV tested, a sizable population remained untested. Specific characteristics associated with sexual minorities' HIV testing status can be used to tailor public health messages and optimize testing rates.

A transparency and accountability framework for high-value inpatient nursing care.

Transparency and accountability are terms that typically refer to activities aimed at measuring and holding providers responsible for their performance through such vehicles as public disclosure of comparative results. Today, transparency and accountability policies are widely accepted strategies to drive quality improvement and stimulate consumer choice. Yet nursing, the single largest health care profession, has not yet been engaged in these policy directions nor considered in their design or implementation. The framework reported here offers nurses and their professional organizations a model for which to advocate for policy change. Hospital and health system executives who have the freedom to establish institutional policies might implement this framework to achieve higher value. This framework provides both the context and components of a system that, if implemented, would measure, report, and reward hospital nursing's contributions to high value.

The contribution of nursing to high-value inpatient care.

Reports of suboptimal health care quality and rising expenditures have led payers to institute policies intended to improve outcomes and lower costs. Referred to as value--driven health care, these policies have multiplied in recent years. Despite their appeal, nursing--the nation's single largest provider of health care-has largely been excluded from these policy directions. This article describes the nature of the evidence substantiating nursing's contribution to quality and cost and explores the reasons--scientific, economic, societal, and political--that these contributions have been largely ignored in the formulation of federal policy. Recommendations are made to strengthen the nurse-value case and convince health care stakeholders, including policy makers, that the relationship is established, enduring, and sufficient for national action.

Transitions of elders between long-term care and hospitals.

Elderly long-term care recipients who require acute hospitalizations must navigate a fragmented system with poor "handoffs," often resulting in negative outcomes. This article makes the case that reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders. Immediate action targeting diffusion of evidence-based care is recommended to decrease avoidable rehospitalizations and achieve cost savings. Policy changes are needed to address barriers to high-quality transitional care, including deficits in health professionals' and caregivers' knowledge and resources, regulatory obstacles, and inadequate financial incentives and clinical information systems.

Trends in transparency: nursing performance measurement and reporting.

The Institute of Medicine proposes a healthcare system with greater transparency for patients and their families. And yet, the extent to which nursing-sensitive performance measures have been adopted and publicly reported is relatively modest. As a step toward achieving greater transparency, the authors briefly describe the state of nursing-sensitive performance measurement and summarize a study completed by the National Quality Forum in 2007. With this information, nursing leaders can help accelerate the adoption of nursing-sensitive quality measures.