Factors associated with memory of informal caregivers: A scoping review protocol.

The ability to retain and remember information (memory) is essential to caregiving tasks. There is evidence that caregivers are at greater risk for experiencing deteriorations in cognitive status than non-caregivers, especially memory; however, we have a limited understanding of factors that are related to changes in caregiver memory. This scoping review intends to comprehensively map factors related to caregiver memory reported in the literature within the chronic caregiving context. Specific aims include (1) identifying factors related to caregiver memory; (2) examining how caregiver memory has been measured; and (3) describing changes in caregiver memory during their caregiving period. This review will be conducted following Arksey and O'Malley's framework and reported using the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). Studies will be included if (1) the studies focus on home-based unpaid long term family caregiving; (2) study participants (patients), of any age, have one (or more) chronic illness or disability and receive care from a caregiver for 6 months or more; (3) caregivers are adults (> = 18 years of age). Any chronic disease or condition will be included. The search will encompass gray literature and peer-reviewed literature in MEDLINE (via Ovid), CINAHL Plus with Full Text (via EBSCOhost), Embase (via Elsevier), APA PsycINFO (via EBSCOhost), Sociology Source Ultimate (via EBSCOhost), and ProQuest Dissertations and Theses Global. Data extraction will include specific details about the participants, concept, context, study methods, and key caregiver-related findings. The Caregiver Health Model will provide a framework to categorize factors that impact caregivers' memory including caregiver health promotion activities, caregiver attitudes and beliefs, caregiver task, and caregiver needs. Factors that do not fall into the Caregiver Health Model domains will be organized by emerging themes.

The Association of Self-esteem With Caregiving Demands, Coping, Burden, and Health Among Caregivers of Breast Cancer Patients: A Structural Equation Modeling Approach.

BACKGROUND: We investigated how caregiver self-esteem was associated with caregiving demands, coping, burden, and health. OBJECTIVE: The aim of this study was to investigate how caregiver self-esteem is associated with caregiving demands, coping, burden, and health. METHODS: Sixty-one caregivers of breast cancer patients were selected from a study conducted at a cancer clinic in the Southeastern region of the United States. Guided by the revised Stress and Coping Theory, a secondary analysis of cross-sectional data was conducted. We used structural equation modeling to analyze paths between caregiver self-esteem and caregiving demands (ie, hours spent on caregiving), coping, burden, and health. RESULTS: Caregivers who effectively coped with stressful situations through strategies such as positive thinking, seeking social support, and problem solving were more likely to have higher levels of self-esteem; in turn, higher levels of self-esteem decreased caregiver burden and improved caregiver overall health. CONCLUSIONS: This study highlights the importance of self-esteem among caregivers of breast cancer patients. Additional research is needed to provide more insight into the influence of coping strategies on caregiver self-esteem, as well as the role of caregiver self-esteem on caregivers' and patients' well-being. IMPLICATION FOR PRACTICE: Healthcare providers need to consider caregiver self-esteem and other associated caregiver characteristics to identify caregivers at risk of higher perceived levels of burden and poor overall health.

Psychological distress among medically complex veterans with a recent emergency department visit.

Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥14 unhealthy days due to poor mental health in the past month) at 30 and 180 days following enrollment in a randomized control trial of 513 medically complex Veterans after a nonpsychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors [baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living (ADL), and deficits in instrumental activities of daily living] with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR = 0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 days assessments, included having the inadequate income (OR = 1.61; 95% CI: 1.02-2.55), having low health literacy (OR = 1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR = 1.94; 95% CI: 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation of health literacy training for clinicians in a federally qualified health center.

Objective: The objective of this quality improvement project was to evaluate the effectiveness of a succinct health literacy training for providers at a demanding federally qualified health center. Methods: One group, pretest-posttest design was used to measure for a change in knowledge regarding the effects of limited health literacy, a change in self-reported measure of routine screening for limited health literacy and a change in self-reported utilization of patient-centered communication techniques. Results: The average percentage of correct responses on the Health Literacy Knowledge Check showed significant improvement from 23.6% (SD = 18.1%) to 63.9% (SD = 25.3%), p < .001. There were no significant changes in median responses at pre- and post-intervention for self-reported use of screening and communication techniques (all p > .05). Conclusion: This brief training was effective at improving participants' knowledge of health literacy but did not improve use of recommended communication techniques or screening for health literacy. The results suggest that emphasizing a universal precautions approach to health literacy may be more effective with participants who work in high-volume clinics. Practice implications: For high-volume clinics, a brief training may improve participants' knowledge but does not increase use of actual communication techniques based on self-report.

Group Coaching Among African-American Individuals with Prediabetes in a Faith-Based Setting.

Roughly 88 million adults have prediabetes and over 84% are unaware that they even have prediabetes. African-Americans have an increased risk of being diagnosed with prediabetes. Faith-based organizations have a history of serving as a primary source of social support for African-Americans. Parishioners with prediabetes from four African-American churches participated in free, evidence-based group coaching to learn how to manage and control risk factors associated with type 2 diabetes. The weekly group coaching sessions took place at a local church and they were co-facilitated by two trained professionals: a lifestyle coach and a nurse practitioner. At the conclusion of the 16-week group coaching sessions, participants had a decrease in hemoglobin A1C levels, an increase in minutes of physical activity per week, and an improvement in knowledge and behavior.

A Competency-Based Orientation (CBO) Protocol Enhances Competency Among Newly Hired Perianesthesia Nurses.

PURPOSE: The purpose of this quality improvement project was to develop a competency-based orientation (CBO) protocol based on the American Society of PeriAnesthesia Nurses Nursing Standards and CBO for perianesthesia nurses. DESIGN: Feasibility study with pre-post survey design. METHODS: A CBO protocol that included nursing care workflows for 11 common surgical cases was developed and used in orienting newly hired perianesthesia nurses. Newly hired nurses completed a pre-post self-assessment on their level of competency in caring for surgical patients. FINDINGS: Using Wilcoxon signed rank test, improved competency was found in all service areas except for pediatric care. CONCLUSIONS: Nursing competency in the perianesthesia area is critical in fulfilling one's role as a nurse. A robust CBO protocol for the perianesthesia nurse is important when integrating an employee into the organization and preparing the nurse for success.

Caregiver Characteristics Associated With Cognitive Complaints in Women With Breast Cancer.

OBJECTIVES: To explore whether caregiver characteristics were associated with cognitive complaints reported by women with breast cancer undergoing chemotherapy. SAMPLE & SETTING: 61 dyads of women with breast cancer and their caregivers were recruited at Duke Women's Cancer Care Raleigh in North Carolina. METHODS & VARIABLES: An exploratory, cross-sectional design was used. Data were obtained on patients and caregivers. Patient cognitive complaints were represented by cognitive impairment (CI) and cognitive ability (CA). RESULTS: Two significant associations were found. IMPLICATIONS FOR NURSING: Healthcare providers should consider caregivers when assessing and managing patients' cognitive symptoms. This study suggests the value of including caregivers when establishing interventions for patients who have cognitive complaints.

Exploring the challenges and needs of home caregivers of hemodialysis patients in the Philippines: A mixed methods study.

OBJECTIVES: Although the importance of home caregivers of chronic kidney disease patients has been increasingly recognized, their perceived caregiving difficulties and requisites remain underexplored. This study investigated the challenges and needs of home caregivers of hemodialysis patients in the Philippines. METHODS: We utilized a mixed-method (QUAN + qual), explanatory sequential design. Data were collected from July 2017 to May 2018 from 46 home caregivers of hemodialysis patients. A three-part researcher-made survey were developed from literature search, personal values and cultural context, while some items were generated from a standardized tool that measures caregiver infrastructure and needs of those caring from frail US veterans. The tool developed gathered the participants' profile, caregiving characteristics, and related needs. The tool was validated and pretested for reliability. Fifteen participants were also interviewed to explore caregiving challenges and needs. Descriptive and χ2 statistics were used for quantitative outcomes, while thematic analysis was employed for qualitative data. RESULTS: Participants provided moderate assistance to patients, spending an average of 10.65 h/day and 5.08 days/week in caregiving. The most difficult caregiving circumstances were having costly expenses (78.26%); missing work (50.00%); and experiencing negative feelings (47.83%), stress (43.48%), and physical difficulties (34.78%). They also had the lowest confidence in deciding when to contact health providers (x̅ = 3.31, SD = 0.94) and finding patient care services (x̅ = 2.93, SD = 1.08). Qualitative findings further revealed caregiving needs and challenges in cost management, physical and psychological health, assumption of multiple roles, lifestyle adjustment, and reinforcement of carer knowledge, skills, and attitudes. CONCLUSION: Supportive strategies are needed to address the challenges encountered by home caregivers of hemodialysis patients. Findings can be utilized in developing appropriate interventions for home caregivers in low-resource settings where home caregiving and healthcare system issues, such as lack of access to resources and social support, are prevalent.

Video-Enhanced Care Management for Medically Complex Older Adults with Cognitive Impairment.

OBJECTIVE: This pilot study assessed feasibility of video-enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery. DESIGN: Pilot randomized controlled trial. SETTING: Durham Veterans Affairs Health Care System. PARTICIPANTS: Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20-31) and their care partners. INTERVENTION: The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone. MEASUREMENTS: Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability. RESULTS: Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm. CONCLUSION: Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.

Quality improvement study on early recognition and intervention of caregiver burden in a tertiary hospital.

BACKGROUND: Caregivers play a crucial role in taking over the important task of looking after patients post-hospitalisation. Caregivers who are unfamiliar with patients' post-discharge care often experience caregiver stress, while patients may see deterioration in their condition. As caregivers are our core partners in healthcare, it is therefore necessary for patient navigators to recognise, assess and address caregivers' needs or burden as early as on admission to hospital. Patient navigators are trained registered nurses whose main role is to provide patients and caregivers with personalised guidance through the complex healthcare system. OBJECTIVES: This quality improvement study examined the efficacy of using the Zarit Burden Interview as a tool in helping patient navigators recognise caregiver burden early and the effectiveness of targeted interventions on caregiver burden. METHODS: Various quality improvement tools were used. Eighty-six patient-caregiver dyads who met the inclusion criteria were enrolled. Informal caregivers were assessed for caregiver burden using the Zarit Burden Interview during hospital admission (T0) and again at 30 days postdischarge (T1), post-intervention. RESULTS: There was significant improvement in the Zarit Burden mean scores from T0 to T1 reported for the 80 dyads who completed the study, even after adjusting for covariates (T0 mean=11.08, SD=7.64; T1 mean=2.48, SD=3.36, positive ranks, p<0.001). Highest burden identified by most caregivers were the personal strain; trying to meet other responsibilities and uncertain about what to do in caring for their loved one. By recognising the different aspects of caregiver burden early, patient navigators were able to focus their interventions. CONCLUSION: Early recognition of caregiver burden and targeted interventions were found to be effective at reducing caregiver burden in a tertiary hospital.

Academic-Practice Partnership for Caregiver Training and Support: The Duke Elder Family/Caregiver Training (DEFT) Center.

BACKGROUND After a hospital stay, many older adults rely on their caregivers for assistance at home. Empirical evidence demonstrates that caregiver support programs in hospital-to-home transitions are associated with favorable caregiver and patient outcomes. We tested the feasibility of implementing the Duke Elder Family/Caregiver Training (DEFT) program in an academic medical center.METHODS: We recruited adult caregivers of homebound patients who were aged 55 years or older from Duke University Hospital in Durham, North Carolina. Caregivers attended a face-to-face caregiver training and received two telephone checks after hospital discharge with DEFT services ending at 14 days of hospital discharge. We used a one-item survey to measure overall DEFT satisfaction. We also monitored 30-day readmissions of patients whose caregivers completed the DEFT program.RESULTS: The DEFT Center received 104 consult orders in six months. Of these, 61 agreed to participate but nine caregivers were unable to schedule the DEFT training and three decided to eventually withdraw from participation. Forty-nine caregivers received the DEFT training, 12 of whom were ineligible to continue because of change in patients' disposition plan. Of the remaining 37 caregivers, 15 completed the full program and reported high satisfaction; one patient was readmitted within 30 days of discharge.LIMITATIONS: The DEFT implementation was based on academic-medical partnership and relied on electronic medical records for consult and documentation. Replicability and generalizability of findings are limited to settings with similar capabilities and resources.CONCLUSION: The implementation of a caregiver training and support program in an academic medical center was feasible and was associated with favorable preliminary outcomes.

Understanding the Associations between Caregiver Characteristics and Cognitive Function of Adults with Cancer: A Scoping Review.

Cognitive impairment (CI) is one of symptoms that adults with cancer frequently report. Although there are known factors that contribute to a patient's CI, these factors did not sufficiently explain its variability. Several studies conducted in patients with neurocognitive disorders have reported relationships between patients' cognitive function and caregiver characteristics, which are poorly understood in the context of cancer. This scoping review aims to map the literature on caregiver characteristics associated with CI in adults with cancer. We used the framework proposed by Arksey and O'Malley and PRISMA-Sc. Studies published in English by 2019 were searched through seven electronic databases. All retrieved citations were independently screened and eligibility for inclusion was determined by two independent authors. Ten studies met inclusion for this review with all of them showing significant associations between a patient's cognitive function and caregiver characteristics. Caregiver's mental health was the most commonly associated with a patient's cognitive function followed by family functioning, adaptation to illness, attitude toward disclosure of the illness, burden, coping and resilience, and demographic characteristics. These review findings suggest that enhanced information about CI in relation to caregiver characteristics will eventually provide the foundation for multifocal interventions for patients with impaired cognitive function. This scoping review identified caregiver characteristics that are associated with patients CI. These characteristics should be also assessed when health providers assess and treat CI of adults with cancer.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial.

BACKGROUND: Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. OBJECTIVE: To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN: Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING: Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS: Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION: The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES: The primary outcome was repeat ED use within 30 days. KEY RESULTS: Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. CONCLUSIONS: A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION: ClinicalTrials.gov NCT01717976.

Caregiver Burden as a Mediator Between Emotional Distress and Concentration Problems in Patients With Cancer.

OBJECTIVES: To examine the longitudinal mediation effect of caregiver burden on the relationship between emotional distress and concentration among individuals with cancer. SAMPLE & SETTING: 96 patients with cancer and their caregivers (96 dyads) were selected from a study conducted at Duke University. METHODS & VARIABLES: A secondary analysis from a longitudinal study was used. Caregiver burden, as well as patients' emotional distress and concentration problems, were selected as variables and analyzed. RESULTS: Caregiver burden acts as a mediator between emotional distress and concentration problems among patients with cancer. More severe caregiver burden is associated with more severe concentration problems for the patient. Dyads with higher patient emotional distress at one week (T1) also had higher caregiver burden at T1, which increased the concentration problems of patients at T1. When caregiver burden became more severe over time, patient concentration problems also increased. IMPLICATIONS FOR NURSING: Healthcare providers should assess caregiver burden and identify factors that contribute to increased caregiver burden. Providing support for managing caregiver burden and patients' emotional distress will help improve patients' concentration capacity.

Understanding on the association between informal caregiver characteristics and cognitive function of adults with cancer: a scoping review protocol.

INTRODUCTION: Adults with cancer frequently report symptoms such as decline in cognitive function throughout the trajectory of illness. Patients with cognitive deficits need support and assistance from their informal caregivers and often rely on them to manage their symptoms based on their degree of deficits. Patients spend a significant amount of time with their informal caregivers and become interdependent with each other. In spite of their interdependence, it is unclear whether patients' cognitive outcomes (ie, cognitive function) are associated with their informal caregivers. Therefore, the body of literature related to the association between caregiver characteristics and cognitive function of adults with cancer needs to be fully mapped with assessment for knowledge gaps. METHODS AND ANALYSIS: Methods for this scoping review was informed by the framework proposed by Arksey and O'Malley. Seven electronic databases will be searched: (1) PubMed (MEDLINE), (2) CINAHL, (3) Embase, (4) PsycINFO, (5) Scopus, (6) Sociological Abstracts and (7) ProQuest dissertation abstracts. In addition, the search for grey literature will include the conference abstracts available through Embase, Scopus and Sociological abstracts as well as dissertations available in ProQuest dissertations. All retrieved citations will be independently screened by two authors and eligibility will be determined based on inclusion and exclusion criteria at title and abstract level. Studies meeting inclusion criteria, will be screened at full text level by two reviewers followed by abstraction of included studies. Eligible studies will be collated, summarised and reported using the data charting form that research team developed. ETHICS AND DISSEMINATION: This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal.

Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES), a skills training program for caregivers of persons with functional or cognitive impairments. DESIGN: A two-arm RCT. SETTING: Single Veterans Affairs Medical Center. PARTICIPANTS: Patients and their primary caregivers referred in the past 6 months to home and community-based services or geriatrics clinic. INTERVENTION: All caregivers received usual care. Caregivers in HI-FIVES also received five training calls and four group training sessions. MAIN MEASURES: Cumulative patient days at home 12 months post-randomization, defined as days not in an emergency department, inpatient hospital, or post-acute facility. Secondary outcomes included patients' total VA health care costs, caregiver and patient rating of the patient's experience of VA health care, and caregiver depressive symptoms. RESULTS: Of 241 dyads, caregivers' (patients') mean age was 61 (73) years, 54% (53%) Black and 89% (4%) female. HI-FIVES was associated with a not statistically significant 9% increase in the rate of days at home (95% CI 0.72, 1.65; mean difference 1 day over 12 months). No significant differences were observed in health care costs or caregiver depressive symptoms. Model-estimated mean baseline patient experience of VA care (scale of 0-10) was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p = .27), 0.31 (p = 0.26) at 6 months, and 0.48 (p = 0.03) at 12 months. For caregivers, it was 8.34 (95% CI 8.10, 8.57); the modeled mean difference at 3 months was 0.28 (p = .18), 0.53 (p < .01) at 6 months, and 0.46 (p = 0.054) at 12 months. CONCLUSIONS: HI-FIVES did not increase patients' days at home; it showed sustained improvements in caregivers' and patients' experience of VA care at clinically significant levels, nearly 0.5 points. The training holds promise in increasing an important metric of care quality-reported experience with care.

Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients.

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.

Primary care provider type: Are there differences in patients' intermediate diabetes outcomes?

Growing demand for services is leading primary care organizations to explore new delivery models. One approach incorporates multiple primary care providers on a team. Effective incorporation of multiple clinicians into teams requires well-defined roles, including the usual provider (who provides the majority of primary care) and supplemental providers (who provide a minority of primary care visits). Using data from the Veterans Health Administration, we examined whether differences in diabetes outcomes exist among patients with different types of primary and supplemental providers (physicians, physician assistants (PAs), and NPs). No clinically meaningful differences were observed based on the profession of the usual provider or supplemental provider, or whether physicians provided supplemental care to patients with PAs or NPs as usual providers. These results suggest that physicians, PAs, and NPs can perform a variety of roles depending on the needs of the organization and patient population.