Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic.

Importance: Health care delivery systems rely on a well-prepared and adequately sized registered nurse (RN) workforce. The US RN workforce decreased by more than 100 000 in 2021 during the COVID-19 pandemic-a far greater single-year drop than observed over the past 4 decades. The implication for the longer-term growth of the RN workforce is unknown. Objective: To describe recent trends in RN employment through 2023 and forecast the growth of the RN workforce through 2035. Design, Setting, and Participants: Descriptive analysis of recent trends since the start of the COVID-19 pandemic in RN employment using data from the US Bureau of the Census Current Population Survey and including employed RNs aged 23 to 69 years from 1982 through 2023, and retrospective cohort analysis of employment trends by birth year and age to project the age distribution and employment of RNs through 2035. Main Outcome and Measures: Annual full-time equivalent (FTE) employment of RNs by age, demographics, and sector of employment; forecast of RN workforce by age through 2035. Results: The final sample included 455 085 RN respondents aged 23 to 69 years. After a sharp decline in 2021, RN employment recovered, and the total number of FTE RNs in 2022 and 2023 was 6% higher than in 2019 (3.35 million vs 3.16 million, respectively). Using data on employment, education, and population through 2022, the size of the RN workforce was projected to increase by roughly 1.2 million FTEs to 4.56 million by 2035, close to prepandemic forecasts. Growth will be driven primarily by RNs aged 35 to 49 years, who are projected to compose nearly half (47%) of the RN workforce in 2035, up from 38% in 2022. Conclusions and Relevance: In this study, the rebound in the total size of the US RN workforce during 2022 and 2023 indicates that the earlier drop in RN employment during the first 2 years of the COVID-19 pandemic was likely transitory. Updated forecasts of the future RN workforce are very close to those made before the pandemic.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study.

OBJECTIVE: To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics. DESIGN: Cross-sectional time series study. SETTING: National data from the traditional Medicare insurance program in the USA. PARTICIPANTS: Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken. MAIN OUTCOME MEASURES: The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis. RESULTS: From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%). CONCLUSION: The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Heart rate and autonomic biomarkers distinguish convulsive epileptic vs. functional or dissociative seizures.

OBJECTIVE: 20-40% of individuals whose seizures are not controlled by anti-seizure medications exhibit manifestations comparable to epileptic seizures (ES), but there are no EEG correlates. These events are called functional or dissociative seizures (FDS). Due to limited access to EEG-monitoring and inconclusive results, we aimed to develop an alternative diagnostic tool that distinguishes ES vs. FDS. We evaluated the temporal evolution of ECG-based measures of autonomic function (heart rate variability, HRV) to determine whether they distinguish ES vs. FDS. METHODS: The prospective study includes patients admitted to the University of Rochester Epilepsy Monitoring Unit. Participants are 18-65 years old, without therapies or co-morbidities associated with altered autonomics. A habitual ES or FDS is recorded during admission. HRV analysis is performed to evaluate the temporal changes in autonomic function during the peri­ictal period (150-minutes each pre-/post-ictal). We determined if autonomic measures distinguish ES vs. FDS. RESULTS: The study includes 53 ES and 46 FDS. Temporal evolution of HR and autonomics significantly differ surrounding ES vs. FDS. The pre-to-post-ictal change (delta) in HR differs surrounding ES vs. FDS, stratified for convulsive and non-convulsive events. Post-ictal HR, total autonomic (SDNN & Total Power), vagal (RMSSD & HF), and baroreflex (LF) function differ for convulsive ES vs. convulsive FDS. HR distinguishes non-convulsive ES vs. non-convulsive FDS with ROC>0.7, sensitivity>70%, but specificity<50%. HR-delta and post-ictal HR, SDNN, RMSSD, LF, HF, and Total Power each distinguish convulsive ES vs. convulsive FDS (ROC, 0.83-0.98). Models with HR-delta and post-ictal HR provide the highest diagnostic accuracy for convulsive ES vs. convulsive FDS: 92% sensitivity, 94% specificity, ROC 0.99). SIGNIFICANCE: HR and HRV measures accurately distinguish convulsive, but not non-convulsive, events (ES vs. FDS). Results establish the framework for future studies to apply this diagnostic tool to more heterogeneous populations, and on out-of-hospital recordings, particularly for populations without access to epilepsy monitoring units.

Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019.

OBJECTIVE: To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING: Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN: Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS: We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS: Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS: States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Assessment of a Price Index for Hospital Outpatient Department Services Using Commercial Claims Data in Massachusetts.

This cross-sectional study assesses a market basket price index to evaluate hospital outpatient department price levels and growth.

Marriage, Children, and Sex-Based Differences in Physician Hours and Income.

Importance: A better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities. Objective: To investigate differences in earnings and hours worked for male and female physicians at various ages and family status. Design, Setting, and Participants: This retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019. Exposures: Earned income and work hours. Main Outcomes and Measures: Outcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022. Results: The sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children. Conclusions and Relevance: In this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

An overview and policy implications of national nurse identifier systems: A call for unity and integration.

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

Characteristics of rural registered nurses and the implications for workforce policy.

PURPOSE: Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future. METHODS: We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States. FINDINGS: While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019. CONCLUSIONS: The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

Frequency Of Indirect Billing To Medicare For Nurse Practitioner And Physician Assistant Office Visits.

Nurse practitioners (NPs) and physician assistants (PAs) represent a growing share of the health care workforce, but much of the care they provide cannot be observed in claims data because of indirect (or "incident to") billing, a practice in which visits provided by an NP or PA are billed by a supervising physician. If NPs and PAs bill directly for a visit, Medicare and many private payers pay 85 percent of what is paid to a physician for the same service. Some policy makers have proposed eliminating indirect billing, but the possible impact of such a change is unknown. Using a novel approach that relies on prescriptions to identify indirectly billed visits, we estimated that the number of all NP or PA visits in fee-for-service Medicare data billed indirectly was 10.9 million in 2010 and 30.6 million in 2018. Indirect billing was more common in states with laws restricting NPs' scope of practice. Eliminating indirect billing would have saved Medicare roughly $194 million in 2018, with the greatest decrease in revenue seen among smaller primary care practices, which are more likely to use this form of billing.

The ERG1 K+ Channel and Its Role in Neuronal Health and Disease.

The ERG1 potassium channel, encoded by KCNH2, has long been associated with cardiac electrical excitability. Yet, a growing body of work suggests that ERG1 mediates physiology throughout the human body, including the brain. ERG1 is a regulator of neuronal excitability, ERG1 variants are associated with neuronal diseases (e.g., epilepsy and schizophrenia), and ERG1 serves as a potential therapeutic target for neuronal pathophysiology. This review summarizes the current state-of-the-field regarding the ERG1 channel structure and function, ERG1's relationship to the mammalian brain and highlights key questions that have yet to be answered.

Characteristics of family nurse practitioners and their preparation for practice in rural vs urban employment settings.

BACKGROUND: Policymakers are increasingly interested in using nurse practitioners to provide health care to rural populations, yet little is known about their characteristics and preparation for independent practice. METHODS: We obtained data from the 2018 National Sample Survey of Registered Nurses and compared characteristics of family nurse practitioners (FNPs) employed in rural areas versus those employed in non-rural areas. Regression analysis was used to determine the relationship between the outcome variable of interest, preparation for practice and other covariates. FINDINGS: FNPs practicing in a rural setting felt less prepared for independent practice than their counterparts in non-rural settings except for those prepared with a doctoral degree. DISCUSSION: The majority of FNPs working in rural areas believed they were not as well prepared for independent practice. Because rural FNPs often practice autonomously and without medical back up, nursing educators need to educate FNPs with the skills and knowledge necessary to practice effectively in rural settings.

Nurse Employment During The First Fifteen Months Of The COVID-19 Pandemic.

Analysis of Current Population Survey data suggests a tightening labor market for registered nurses, licensed practical nurses, and nursing assistants, marked by falling employment and rising wages through June 2021. Unemployment rates remain higher in nonhospital settings and among registered nurses and nursing assistants who are members of racial and ethnic minority groups.

Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US.

Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.

Multi-system Monitoring for Identification of Seizures, Arrhythmias and Apnea in Conscious Restrained Rabbits.

Patients with ion channelopathies are at a high risk of developing seizures and fatal cardiac arrhythmias. There is a higher prevalence of heart disease and arrhythmias in people with epilepsy (i.e., epileptic heart.) Additionally, cardiac and autonomic disturbances have been reported surrounding seizures. 1:1,000 epilepsy patients/year die of sudden unexpected death in epilepsy (SUDEP). The mechanisms for SUDEP remain incompletely understood. Electroencephalograms (EEG) and electrocardiograms (ECG) are two techniques routinely used in the clinical setting to detect and study the substrates/triggers for seizures and arrhythmias. While many studies and descriptions of this methodology are in rodents, their cardiac electrical activity differs significantly from humans. This article provides a description of a non-invasive method for recording simultaneous video-EEG-ECG-oximetry-capnography in conscious rabbits. As cardiac electrical function is similar in rabbits and humans, rabbits provide an excellent model of translational diagnostic and therapeutic studies. In addition to outlining the methodology for data acquisition, we discuss the analytical approaches for examining neuro-cardiac electrical function and pathology in rabbits. This includes arrhythmia detection, spectral analysis of EEG and a seizure scale developed for restrained rabbits.

In vivo and in vitro reconstitution of unique key steps in cystobactamid antibiotic biosynthesis.

Cystobactamids are myxobacteria-derived topoisomerase inhibitors with potent anti-Gram-negative activity. They are formed by a non-ribosomal peptide synthetase (NRPS) and consist of tailored para-aminobenzoic acids, connected by a unique α-methoxy-L-isoasparagine or a ß-methoxy-L-asparagine linker moiety. We describe the heterologous expression of the cystobactamid biosynthetic gene cluster (BGC) in Myxococcus xanthus. Targeted gene deletions produce several unnatural cystobactamids. Using in vitro experiments, we reconstitute the key biosynthetic steps of linker formation and shuttling via CysB to the NRPS. The biosynthetic logic involves a previously uncharacterized bifunctional domain found in the stand-alone NRPS module CysH, albicidin biosynthesis and numerous BGCs of unknown natural products. This domain performs either an aminomutase (AM) or an amide dehydratase (DH) type of reaction, depending on the activity of CysJ which hydroxylates CysH-bound L-asparagine. Furthermore, CysQ O-methylates hydroxyl-L-(iso)asparagine only in the presence of the AMDH domain. Taken together, these findings provide direct evidence for unique steps in cystobactamid biosynthesis.