Risk of Hospitalization Associated with Use of Consumer-Directed Attendant Care.

Older people with disabilities living independently often use attendant care, also known as Personal Assistive Services (PAS). The aides providing care can come from a home health agency contracted by the state Medicaid authority, known as agency-directed PAS, or the Medicaid recipient can receive a monthly budget and arrange their own care, known as consumer-directed care. Consumer-directed care is hypothesized to have some possible benefits but could also potentially lead to health hazards. This study examined whether people receiving consumer-directed PAS versus people receiving agency-directed PAS faced a higher risk of hospitalization. The data for this study came from Pennsylvania Medicaid claims, enrollment files, standardized assessments, and hospitalization claims from Medicare and Medicaid. The analysis used two-stage least square regression, with the percentage of people in a county using consumer-directed care as an instrument for the type of PAS. People using consumer-directed care did not have a statistically significant difference in risk for hospitalization compared to people using agency-directed PAS (p = .976). Risk of hospitalization was not different for people using consumer-directed care compared to people using agency-directed care.

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.

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.

Opportunities to Diversify the Pediatric Nursing Workforce: A Focus on Male Nurses.

INTRODUCTION: Pediatric nursing has been a profession dominated by women, but patients benefit from representation of both men and women. We describe characteristics associated with male pediatric nurses and consider potential pathways to greater male pediatric nurse workforce participation. METHOD: We used data from the 2018 National Sample Survey of Registered Nurses, a nationally representative survey of nurses that estimates characteristics of the workforce. We present summary statistics to describe demographic, work setting and work environment characteristics of male and pediatric nurse workforces. Analyses accounted for complex survey design and weighting. RESULTS: Only 7% (N = 108,752) of the pediatric registered nurse workforce and 3% (N = 779) of the pediatric nurse practitioner workforces were male. Notable demographic and educational difference exist among compared workforces. DISCUSSION: Males are significantly underrepresented in pediatric nursing. Much effort and intention need to be directed towards increasing male representation in pediatric nursing.

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.

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.

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.

Primary Care Nurse Practitioner Burnout and ED Use and Hospitalizations Among Chronically Ill Medicare Beneficiaries.

Nurse practitioners (NPs) represent the fastest-growing workforce of primary care clinicians in the United States. Their numbers are projected to grow in the near future. The NP workforce can help the country meet the rising demand for care services due to the aging population and increasing chronic disease burden. Yet, increased burnout among these clinicians may affect their ability to deliver high-quality, safe care. We investigated how NP burnout in primary care practices affects patient outcomes, including emergency department (ED) use and hospitalizations, among older adults with chronic conditions. In 2018-2019, we collected survey data from 1244 primary care NPs from 6 geographically diverse states on their burnout and merged the survey data with data from Medicare claims on ED use and hospitalizations among 467 466 older adults with chronic conditions. 26.3% of NPs reported burnout. Using logistic regression models, we found that with a 1-unit increase in the standardized burnout score, the odds of an ED visit increased by 2.8% (OR = 1.028; P-value = .035); Ambulatory Care Sensitive Conditions (ACSC) ED visit by 3.2% (OR = 1.032; P-value = .019); hospitalization by 3.9% (OR = 1.039; P-value = .001); and ACSC hospitalization by 6.2% (OR = 1.062; P-value = .001). Our findings indicate that if chronically ill older adults receive care in primary care practices with higher NP burnout rates they are more likely to use EDs and hospitals. Policy and practice efforts, such as improving NP working conditions, should be undertaken to reduce NP burnout in primary care practices to potentially prevent acute care use.

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.

The Impact of Primary Care Practice Structural Capabilities on Nurse Practitioner Burnout, Job Satisfaction, and Intent to Leave.

BACKGROUND: Lack of structure for care delivery (ie, structural capabilities) has been linked to lower quality of care and negative patient outcomes. However, little research examines the relationship between practice structural capabilities and nurse practitioner (NP) job outcomes. OBJECTIVES: We investigated the association between structural capabilities and primary care NP job outcomes (ie, burnout, job dissatisfaction, and intent to leave). RESEARCH DESIGN: Secondary analysis of 2018-2019 cross-sectional data. SUBJECTS: A total of 1110 NPs across 1002 primary care practices in 6 states. MEASURES: We estimated linear probability models to assess the association between structural capabilities and NP job outcomes, controlling for NP work environment, demographics, and practice features. RESULTS: The average structural capabilities score (measured on a scale of 0-1) across practices was 0.6 (higher score indicates more structural capabilities). After controlling for potential confounders, we found that a 10-percentage point increase in the structural capabilities score was associated with a 3-percentage point decrease in burnout ( P <0.001), a 2-percentage point decrease in job dissatisfaction ( P <0.001), and a 3-percentage point decrease in intent to leave ( P <0.001). CONCLUSIONS: Primary care NPs report lower burnout, job dissatisfaction, and intent to leave when working in practices with greater structural capabilities for care delivery. These findings suggest that efforts to improve structural capabilities not only facilitate effective care delivery and benefit patients but they also support NPs and strengthen their workforce participation. Practice leaders should further invest in structural capabilities to improve primary care provider job outcomes.

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.

The Multilevel Reliability and Interrater Agreement of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.

Background and Purpose: It is critical to accurately measure and understand the nurse practitioner (NP) work environment in which individual NP information is gathered but decisions or inferences are made at an aggregated, group level. However, there is little research on preconditions of aggregating individual-level data into group level in nursing research. This study was conducted to assess the multilevel reliability and group interrater agreement (IRA) of the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Methods: Secondary data analysis from a cross-sectional survey with 247 NPs in 112 practices across 6 U.S. states in 2018-2019 was used. Results: The generalizability coefficients and values of IRA were acceptable (> .70), and values of ICC(1) were significant (.18-.38). Conclusions: Aggregating individual NP data to a higher group-level work environment construct is acceptable.

Structural capabilities in primary care practices where nurse practitioners care for persons living with dementia.

BACKGROUND: Primary care structural capabilities (i.e., electronic health records, care coordination, community integration, and reminder systems) can address the multiple needs of persons living with dementia (PLWD). OBJECTIVES: This study describes structural capabilities in primary care practices where nurse practitioners (NPs) provide care to PLWD and compares the presence of structural capabilities in practices with a high and low volume of PLWD. METHODS: We conducted a secondary analysis of cross-sectional data from 293 NPs in 259 practices in California. Logistic regression models were used to determine the association between the volume of PLWD and the presence of structural capabilities. RESULTS: NPs reported that 96% of practices had electronic health records, 61% had community integration, 55% had reminder systems and 35% had care coordination capabilities. Practices with a high volume of PLWD were less likely to have community integration compared to practices with a low volume of PLWD. CONCLUSION: Many PLWD-serving practices do not have the essential infrastructure for providing optimal dementia care. Practice managers should focus on implementing the essential structural capabilities to address the complex needs of PLWD. IMPLICATIONS FOR PRACTICE: Clinicians and practice administrations can use the findings of this study to improve the delivery of care in practices that provide care to PLWD.

The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care.

Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.

The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity.

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.

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.

Adherence to Tympanostomy Tube Clinical Practice Guidelines in an Advanced Practice Provider Clinic.

OBJECTIVE: We compared adherence rates by attending otolaryngologists (OTOs) and advanced practice providers (APPs) to the 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) for children with recurrent acute otitis media (RAOM) undergoing bilateral myringotomy and tympanostomy tube placement (BMT). METHODS: Patients aged 6 months to 12 years old undergoing BMT for RAOM who had a pre-operative visit with an independent APP or OTO were reviewed. Patients satisfied CPG criteria if middle ear effusion was identified at the pre-operative visit (pre-op) or if they did not have effusion but met exception criteria based on their risk for developmental difficulties and contraindications to medical therapy. Adherence rates between APPs and OTOs were compared. Agreement between pre-op and time-of-surgery middle ear effusion identification was assessed. RESULTS: Nine hundred twenty-three patients were included. Six hundred one patients were seen by OTOs and 322 by APPs. Middle ear effusion was identified at pre-op in 84% of APP patients and in 76% of OTO patients (P = .005). Eight percent of APP patients and 11% of OTO patients met exception criteria (P = .138). Overall, 87% of OTO patients and 92% of APP patients met either CPG or exception criteria for BMT (P = .037). A logistic regression model demonstrated that pre-op provider type did not significantly impact rates of agreement between pre-op visit and time-of-surgery middle ear effusion identification. CONCLUSIONS: Independent APP-led clinics can reliably and effectively deliver evidence-based care for prevalent conditions such as RAOM at similar rates of adherence to CPGs as OTOs.

State-level scope of practice regulations for nurse practitioners impact work environments: Six state investigation.

Nurse practitioner (NP) scope of practice (SOP) policies are different across the United States. Little is known about their impact on NP work environment in healthcare organizations. We investigated the association between SOP policies and organizational-level work environment of NPs. Through a cross-sectional survey design, data were collected from 1244 NPs in six states with variable SOP regulations (Arizona, New Jersey, Washington, Pennsylvania, Texas, and California) in 2018-2019. Arizona and Washington had full SOP-NPs had full authority to deliver care. New Jersey and Pennsylvania had reduced SOP with physician collaboration requirement; California and Texas had restricted SOP with physician supervision requirement. NPs completed mail or online surveys containing the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has these subscales: NP-Administration Relations (NP-AR), NP-Physician Relations (NP-PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models assessed the relationship between state-level SOP and practice-level NP work environment. NP-AR scores were higher in full SOP states compared to reduced (ß = 0.22, p < 0.01) and restricted (ß = 0.15, p < 0.01) SOP states. Similarly, IPS scores were higher in full SOP states. The PV scores were also higher in full SOP states compared to reduced (ß = 0.16, p < 0.001) and restricted (ß = 0.12, p < 0.05) SOP states. There was no relationship between SOP and NP-PR score. State-level policies affect NP work environment. In states with more favorable policies, NPs have better relationships with administration and report more role visibility and support. Efforts should be made to remove unnecessary SOP restrictions.