Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease.

BACKGROUND: Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients. OBJECTIVE: To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease. DESIGN: In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease. PARTICIPANTS: A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included. MAIN MEASURES: All-cause and ambulatory care sensitive condition hospitalizations in 2018. KEY RESULTS: There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries. CONCLUSIONS: Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels.

BACKGROUND: Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored. PURPOSE: To estimate the impact of NP panel management on workforce outcomes. METHODS: Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management. DISCUSSION: Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours. CONCLUSION: Interventions to reduce work hours could help NPs deliver quality care without burnout.

The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring.

Demand for acute care is forecasted to grow in the United States. To meet this demand, nurse practitioners (NPs) are increasingly employed in acute care settings. Yet, there is concern about an adequate supply of acute care NPs given demand. Further, professional nursing organizations recommend aligning an NP's role with their education, certification, licensure, and practice. Given workforce constraints and the policy environment, little is known about how hospitals approach hiring NPs for acute care roles. The purpose of this study was to explore advanced practice provider (APP) directors' approaches to hiring NPs within the context of alignment and describe factors that influence hiring decisions. We conducted semi-structured interviews with 17 APP directors in hospitals and health systems. Interviews were recorded, transcribed, and coded using an iterative, hybrid inductive and deductive method. Two themes emerged: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments. Practices around hiring NPs varied across institutions influenced by organization and state policies and regulations, workforce availability, and institutional culture. Most APP directors recognized trends towards hiring aligned NPs for acute care roles. However, they also identified barriers to fully aligning their NP workforce and described adaptive strategies including hiring physician assistants, building relationships with APP schools, and leveraging hospital resources to develop the APP workforce to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications of alignment for patient and organizational outcomes.

Describing the male registered nursing workforce toward increasing male representation in professional nursing.

BACKGROUND: Men are significantly underrepresented in nursing and increasing their numbers should be a priority. PURPOSE: To describe the male nursing workforce in terms of size, demographics, education, and work settings. METHODS: Using data from the 2018 National Sample Survey of Registered Nurses, we performed a secondary descriptive analysis. FINDINGS: We find that 9.6% of registered nurses are men. Men are more likely than women to hold an associate degree and clinical doctorates, be nurse anesthetists and supervisors, and work in emergency settings but less likely than females to participate in teaching. DISCUSSION: To increase male representation in nursing we must simultaneously rearticulate what it means for a job to be "female" while also showing that nursing incorporates many skills and interests traditionally coded as "male." We can also show men that nursing offers appealing employment that can lead to a deeply fulfilling personal and professional life.

Advancement of research on nurse practitioners: Setting a research agenda.

BACKGROUND: Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE: We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS: Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION: The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION: The agenda can advance evidence on the NP workforce to guide policy and practice.

Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions.

BACKGROUND: Integrating mental health in primary care settings is associated with improved screening and detection of mental illness. In 2010, the Veterans Health Administration launched a patient-centered medical home (PCMH) model nationally across all clinical sites that integrated mental health into primary care-the Patient Aligned Care Team (PACT) initiative. Team-based delivery of continuous primary and mental health care, as found in effective collaborative care models, is thought to be crucial to managing veterans with mental health disorders. The association between clinic implementation of specific aspects of PACT and clinical outcomes of veterans with mental health disorders remains unknown. OBJECTIVE: To examine the association between clinic implementation of team-based care and continuity of care and subsequent hospitalizations among veterans with mental health disorders. DESIGN: Retrospective cohort study. PATIENTS: A total of 1,444,942 veterans with comorbid mental health disorders and physical health conditions receiving primary care in 831 VA PACT clinics in fiscal year (FY) 2015. MAIN MEASURES: We examined the clinic-level implementation of team-based care and continuity of care in the clinic where veterans received their primary care. Our primary outcome was any hospitalization in the VA or fee-based service in FY2016. We examined the impact of clinic-level implementation of team-based care and continuity of care on having a hospitalization, adjusting for patient demographic, clinical characteristics, and facility characteristics. KEY RESULTS: Veterans receiving care in clinics with the greatest versus lowest quartile of implementation of team-based care had lower rates of hospitalization (8.8% vs. 12.3%; adjusted OR = 0.92, 95% CI 0.85-0.99, p < 0.035). There was not a statistically significant association between clinic-level implementation of continuity of care and hospitalization. CONCLUSIONS: Veterans receiving care in clinics with greater implementation of team-based care had statistically significant lower rates of hospitalization.

Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis.

BACKGROUND: Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. PURPOSE: The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. METHODS: Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. RESULTS: Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. CONCLUSION: NP and PA employment was positively associated with increases in Medicaid participation. PRACTICE IMPLICATIONS: As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.

State responses to COVID-19: Potential benefits of continuing full practice authority for primary care nurse practitioners.

BACKGROUND: During the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions. PURPOSE: To support policy makers' efforts to grant full practice authority to NPs beyond the COVID-19 pandemic, this manuscript summarizes the existing evidence on the benefits of permanently removing state-level scope of practice barriers and outline recommendations for policy, practice, and research. METHODS: We have conducted a thorough review of the existing literature. FINDINGS: NP full scope of practice improves access and quality of care and leads to better patient outcomes. It also has the potential to reduce health care cost. DISCUSSION: The changes to support full practice authority enacted to address COVID-19 are temporary. NP full practice authority could be part of a longer-term plan to address healthcare inequities and deficiencies rather than merely a crisis measure.

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.

Psychiatric Medication Changes Associated With Increased Rate of Medical Readmissions in Patients With Serious Mental Illness.

ABSTRACT: To identify the impact of postdischarge psychiatric medication changes on general medical readmissions among patients with serious mental illness (SMI; bipolar disorder, major depressive disorder, and schizophrenia), claims from a 5% national sample of Medicare fee-for-service (FFS) beneficiaries hospitalized between 2013 and 2016 were studied. A total of 165,490 Medicare FFS beneficiaries with SMI 18 years or older with at least 1 year of continuous Medicare enrollment were identified. Within 30 days of discharge from index admission, 47.4% experienced a psychiatric medication change-including 75,892 beneficiaries experiencing a deletion and 55,713 experiencing an addition. After adjusting for potential confounders, those with a medication change experienced an 10% increase in the odds of 30-day readmission (odds ratio, 1.10; SE, 0.019; p < 0.001). Comorbid drug use disorder was also associated with an increased odds of readmission after controlling for other covariates. These findings suggest important factors that clinicians should be aware of when discharging patients with SMI.

Community socioeconomic disadvantage drives type of 30-day medical-surgical revisits among patients with serious mental illness.

BACKGROUND: Patients with serious mental illness (SMI) are vulnerable to medical-surgical readmissions and emergency department visits. METHODS: We studied 1,914,619 patients with SMI discharged after medical-surgical admissions in Florida and New York between 2012 and 2015 and their revisits to the hospital within 30 days of discharge. RESULTS: Patients with SMI from the most disadvantaged communities had greater adjusted 30-day revisit rates than patients from less disadvantaged communities. Among those that experienced a revisit, patients from the most disadvantaged communities had 7.3 % greater 30-day observation stay revisits. CONCLUSIONS: These results suggest that additional investments are needed to ensure that patients with SMI from the most disadvantaged communities are receiving appropriate post-discharge care.

Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists.

BACKGROUND: Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care. PURPOSE: We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce. METHOD: Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs. FINDINGS: Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs. DISCUSSION: We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

Practice environment, independence, and roles among DNP- and MSN-prepared primary care nurse practitioners.

BACKGROUND: Many nursing schools are adopting the Doctor of Nursing Practice (DNP) as the preferred model of nurse practitioner (NP) education and eliminating Master of Science in Nursing (MSN) programs. To date, no studies have explored the relationship between DNP preparation and NP practice environment, independence, and roles. PURPOSE: The purpos of this study is to compare practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. METHODS: This study used a cross-sectional design and observational regression analysis of survey data. FINDINGS: DNP-prepared NPs reported: 1) more favorable NP-Physician Relationships, 2) fewer clinical hours, and 3) more practice leadership. These differences were, however, small and not significant at 0.05 level. DISCUSSION: We found no major differences in practice environment, independence, and roles among DNP- and MSN-prepared primary care NPs. As more nursing schools establish DNP programs and more DNP-prepared NPs enter the field, it is especially important to continue to study the impact of DNP preparation on the NP workforce.

Methodology for a six-state survey of primary care nurse practitioners.

BACKGROUND: Primary care practices employing nurse practitioners (NPs) can play an important role in improving access to high quality health care services. However, most studies on the NP role in health care use administrative data, which have many limitations. PURPOSE: In this paper, we report the methods of the largest survey of primary care NPs to date. METHODS: To overcome the limitations of administrative data, we fielded a cross-sectional, mixed-mode (mail/online) survey of primary care NPs in six states to collect data directly from NPs on their clinical roles and practice environments. FINDINGS: While we were able to collect data from over 1,200 NPs, we encountered several challenges with our sampling frame, including provider turnover and challenges with identification of NP specialty. DISCUSSION: In future surveys, researchers can employ strategies to avoid the issues we encountered with the sampling frame and enhance large scale survey data collection from NPs.

Top priorities for the next decade of nursing health services research.

BACKGROUND: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION: The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.

Implications of State Scope-of-Practice Regulations for Pediatric Intensive Care Unit Nurse Practitioner Roles.

Nurse practitioner (NP) advocacy efforts often focus on attaining full practice authority. While the effects of full practice authority in primary care are well described, implications for hospital-based NPs are less clear and may differ because of hospitals' team-based care and administrative structure. This study examines associations between state scope-of-practice (SSOP) and clinical roles of hospital-based pediatric intensive care unit (PICU) NPs. We conducted a national survey to assess clinical roles of PICU NPs including daily patient care, procedural, and consultation responsibilities as well as hospital-level administrative oversight practices. We classified SSOP as full or limited (reduced or restricted SSOP) practice. We present descriptive statistics and evaluate differences in clinical roles and hospital-level administrative oversight based on SSOP. The final sample included 55 medical directors and 58 lead (senior or supervisory) NPs from 93 of the 140 (66.4%) PICUs with NPs. There were no significant differences in daily patient care, procedural, or consultation responsibilities based on SSOP (p > .05). However, NPs in full practice authority states were more likely to bill for care than those in limited practice states (66.7% vs. 31.8%, p = .003), while those in limited practice states were more likely to report to advanced practice managers (36.7% vs. 13%, p = .03). For PICU NPs, SSOP was not associated with variation in clinical responsibilities; conversely, there were differences in billing and reporting practices. Future work is needed to understand implications of variation in hospital-level administrative oversight.

Surveying Primary Care Nurse Practitioners: An Overview of National Sampling Frames.

Nurse practitioners (NPs) represent the fastest growing segment of the U.S. primary care workforce. Surveys of primary care NPs can help to better understand the care NPs deliver across different health care settings, the factors that impact NP job satisfaction and burnout, and the structural capabilities required to support their practice. The purpose of this article is to provide an overview of national sampling frames that can be used by researchers interested in surveying or studying the U.S. primary care NP workforce. We conducted an environmental scan and review of published literature on the NP workforce to identify data sources that can be used to sample primary care NPs. In this article, we (a) identify the data elements needed to develop an NP sampling frame and (b) describe national data sets that can be used to sample primary care NPs, including the strengths and weaknesses of each. This information is intended to facilitate research on the primary care NP workforce to inform practice and policy.

Economic Analysis of Mandated Protocolized Sepsis Care in New York Hospitals.

OBJECTIVES: Initial evidence suggests that state-level regulatory mandates for sepsis quality improvement are associated with decreased sepsis mortality. However, sepsis mandates require financial investments on the part of hospitals and may lead to increased spending. We evaluated the effects of the 2013 New York State sepsis regulations on the costs of care for patients hospitalized with sepsis. DESIGN: Retrospective cohort study using state discharge data from the U.S. Healthcare Costs and Utilization Project and a comparative interrupted time series analytic approach. Costs were calculated from admission-level charge data using hospital-specific cost-to-charge ratios. SETTING: General, short stay, acute care hospitals in New York, and four control states: Florida, Massachusetts, Maryland, and New Jersey. PATIENTS: All patients hospitalized with sepsis between January 1, 2011, and September 30, 2015. INTERVENTIONS: The 2013 New York mandate that all hospitals develop and implement protocols for sepsis identification and treatment, educate staff, and report performance data to the state. MEASUREMENTS AND MAIN RESULTS: The analysis included 1,026,664 admissions in 520 hospitals. Mean unadjusted costs per hospitalization in New York State were $42,036 ± $60,940 in the pre-regulation period and $39,719 ± $59,063 in the post-regulation period, compared with $34,642 ± $52,403 pre-regulation and $31,414 ± $48,155 post-regulation in control states. In the comparative interrupted time series analysis, the regulations were not associated with a significant difference in risk-adjusted mean cost per hospitalization (p = 0.12) or risk-adjusted mean cost per hospital day (p = 0.44). For example, in the 10th quarter after implementation of the regulations, risk-adjusted mean cost per hospitalization was $3,627 (95% CI, -$681 to $7,934) more than expected in New York State relative to control states. CONCLUSIONS: Mandated protocolized sepsis care was not associated with significant changes in hospital costs in patients hospitalized with sepsis in New York State.

Misalignment of specialty nurse practitioners and the Consensus Model.

Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.

Relationship Between State Policy and Anesthesia Provider Supply in Rural Communities.

BACKGROUND: There is a significant geographic variation in anesthesia provider supply. Lower supply in rural communities raises concerns about access to procedures that require anesthesia in rural areas. State policies related to certified registered nurse anesthetist (CRNA) practice may help to alleviate rural supply concerns. OBJECTIVES: To estimate the association between state CRNA policy and anesthesia provider supply especially in rural communities. RESEARCH DESIGN: Repeated cross-sectional design using ordinary least squares and 2-stage least squares regressions. SUBJECTS: All counties in the United States from 2010 to 2015. MEASURES: Dependent variables include anesthesia provider counts per 100,000 people, calculated separately for anesthesiologists, CRNAs, and their sum. Key variables of interest include state-level CRNA policy based on scope of practice (SOP) regulations and Medicare opt-out status. RESULTS: Opt-out status and less restrictive SOP regulations were consistently correlated with a greater supply of CRNAs, especially in rural counties. Furthermore, we found that anesthesiologists and CRNAs tend to be complements to each other, but less restrictive SOP and opt-out status tend to weaken the importance of this relationship. CONCLUSIONS: State regulations may lead to increased supply of CRNAs in rural communities. However, the design of our study makes causality difficult to assert. So, it is also possible that states set CRNA policy as a response to counts of anesthesia providers in rural areas. Furthermore, given supply of anesthesiologists and CRNAs are complementary to one another, improving access to anesthesia services may require addressing issues pertaining to the supply of all anesthesia provider types.