The effects of dental hygienist autonomy on dental care utilization.

We investigate the effects of regulations governing the practice autonomy of dental hygienists on dental care use with the 2001-2014 Medical Expenditure Panel Survey. We measure the strength of autonomy regulations by extending the Dental Hygiene Professional Practice Index to the years 2001-2014, allowing us to capture changes in regulations within states over time. Using a difference-in-differences framework applied to selected states, we find that relaxing supervision requirements to provide dental hygienists moderate autonomy results in an increase in total dental visits due to greater use of preventive dental care. However, the use of dental treatment decreases when states adopt the highest level of autonomy. Both sets of estimates increase in magnitude when we subset the sample to dental care provider shortage areas. In support of these findings, we show that dental visits shift to dental hygienists in shortage areas when states expand the scope of practice of hygienists, and that there is an increase in tasks performed by hygienists, such as cleanings and dental exams.

Advanced Practice Registered Nurse Full Practice Authority, Provider Supply, and Health Outcomes: A Border Analysis.

Due to a growing physician shortage, patients have difficulty accessing primary care. In an effort to expand access and support patient health, many states are reducing barriers for advanced practice registered nurses to provide primary care without physician collaboration. Maryland provides an interesting case study. We leverage Maryland's policy change to explore the effects of full practice authority (FPA), focusing on the number of professionals and health outcomes for patients. Employing a border county comparison between Maryland and Pennsylvania, we estimate the effect of FPA. Our analysis of health outcomes focuses on three county-level health outcomes: poor or fair health, poor mental health days, and preventable hospital stays. We find that FPA is associated with increases in the number of certified nurse midwives by 0.6 per 100,000 residents and nurse practitioners by 22.4 per 100,000 residents. We also find evidence of an association of FPA with reductions in the share of residents who report being in poor or fair health by 2.8 percentage points and poor mental health days per month by 0.354 days per person. Combined, our results provide suggestive evidence that moving to FPA improves access to care and leads to improved health outcomes for Maryland residents. Removing regulatory barriers that prevent certified nurse midwives and nurse practitioners from working to the full extent of their training may increase access to primary care and improve patient 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.

Exploring the Relationship between Nurse Practitioner Full Practice Authority, Nurse Practitioner Workforce Diversity, and Disparate Primary Care Access.

In this study, we examine how full nurse practitioner (NP) practice authority affects racial and ethnic diversity of the NP workforce. Specifically, the purpose of our research is to understand the relationship between the racial and ethnic composition of the NP workforce, NP level of practice authority, and the communities they service. In this paper, we compare the ethnic and racial composition of the NP workforce to the composition of the state's population, and then observe if there are any noticeable differences in the patients served by NPs when we compare full practice authority (FPA) and non-FPA states. We also estimate how FPA affects the race and ethnicity of Medicare patients served by NPs.

Estimating the Effect of the New York State Nurse Practitioners Modernization Act on Care Received by Medicaid Patients.

The demand for primary care services may surpass the supply of primary care providers, exacerbating challenges with access, quality, and cost in the U.S. health care system. Expanding the supply of, and access to, nurse practitioner (NP) care has been proposed as one method to alleviate these challenges. New York State (NYS) changed its regulatory environment for NPs in 2015. We estimate the impact of expanded NP scope of practice (SOP) regulations in NYS on total care days received by Medicaid beneficiaries from 2015 to 2018 using a model derived from national historical data from 1999 to 2011. We used a longitudinal data policy analysis framework and a generalized difference-in-differences model to identify the effect of changes in NP SOP regulations on total care days. The model included controls for state income and unemployment rates. Our results suggest that the policy change increased total care days provided to patients, but that this difference was not statistically significant and became negligible after computing the number of days per beneficiary. In addition, our results suggest that had NYS moved to a full practice environment, more care days could have been provided to Medicaid patients, and this difference was found to be statistically significant. Our results suggest that states should adopt full NP SOP practice environments to realize measurable benefits of expanded NP SOP.

Estimating the effect of New Jersey's 2005 administrative nurse mandate on mortality and hospitalizations for medicare hemodialysis patients.

BACKGROUND AND OBJECTIVES: In 2005, the New Jersey Department of Health enacted a rule requiring that an administrator or designate always be present in a hemodialysis clinic and that the individual may not be involved in patient care activities at any time. Our investigation examines the effect of this unique rule on patient mortality and hospitalizations and is meant to inform the public policy discussion. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: We utilized a synthetic control estimation to analyze the effect of this rule on patient mortality in New Jersey. We also compared trends for hospitalizations in New Jersey to other similar states. RESULTS: We find no evidence that the law affected patient mortality or the number of hospitalizations for Medicare patients in New Jersey. CONCLUSIONS: The New Jersey law poses substantial costs to hemodialysis clinics and we find little evidence of any measurable benefit to patients.

Estimating the effect of dialysis staffing ratio regulations on mortality and hospitalizations for Medicare hemodialysis patients.

BACKGROUND AND OBJECTIVES: Eight states and Washington, DC have implemented regulations mandating a minimum ratio between treatment staff and patients receiving hemodialysis in a facility in an effort to improve the quality of hemodialysis treatment. Our investigation examines the association between minimum staffing regulations and patient mortality for four states and hospitalizations for two states that implemented these rules during our sample period. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: We utilized a synthetic difference in differences estimation to analyze the effect of minimum staffing ratios on hemodialysis treatment quality, measured by deaths and hospitalizations for end-stage renal disease patients. We used data gathered by the US Renal Data System and aggregated at the state level. RESULTS: We are unable to find evidence that mandated dialysis staffing ratios area associated with a reduction in mortality or hospitalizations. We estimate a slight reduction in deaths per 1000 patient hours and a slight increase in hospitalizations, but neither are statistically significant. CONCLUSIONS: We were unable to find evidence that minimum staffing ratios for hemodialysis facilities are associated with improved patient outcomes. Our findings highlight the need for future work, studying the impact of these regulations at the facility level.

Potential licensing reforms in light of COVID-19.

In 2020, COVID-19 threatened to overwhelm healthcare capacity, forcing policymakers to enact temporary waivers of licensing restrictions. Research finds that occupational licensing reduces the supply of professionals in a regulated field, and reduces geographic mobility, contributing to the primary care professional shortage. Scope of practice laws reduce the flexibility of practitioners, exacerbating these shortages. Given the fact that policymakers and healthcare professionals recognized the shortcomings to our current licensing regime during the COVID-19 pandemic, we should consider alternatives that still ensure quality care for patients without restricting access and reducing flexibility. We rank six alternatives currently being considered to address the primary care shortage from most to least effective. While efforts to expand the supply of physicians or NPs and PAs would be the most effective reforms to expand access to primary care, others that better utilize our existing supply of healthcare professionals are worth considering.

Smoking, parent smoking, depressed mood, and suicidal ideation in teens.

OBJECTIVES: We address whether smoking is related to suicidal ideation in teens and whether there is evidence of a causal pathway. METHODS: We use data from the 2002 National Annenberg Survey of Youth and employ multivariate logistic regression to model each teen's risk of suicidal ideation as a function of self-report of depressive symptoms, own smoking, parent smoking, and demographic and household income variables. RESULTS: Individuals reporting depressive symptoms have an increased risk of suicidal ideation (odds ratio [OR] = 13.13; 95% CI = 5.98-28.81). Relative to teens who do not smoke and whose parents do not smoke, teens who smoke and do not have a parent who smokes have increased risk of suicidal ideation (OR = 8.10; 95% CI = 2.88-22.80), whereas those with a parent who smokes do not have a statistically significant increased risk of suicidal ideation regardless of teen smoking behavior. CONCLUSION: Relative to teens who do not smoke and do not have parents who smoke, suicidal ideation risk is increased in teens who smoke only if they do not have a parent who smokes. We find evidence that the smoking and suicidal ideation of the teens is likely due to common psychosocial causes rather than a causal pathway from smoking to suicidal ideation.

The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care.

The provision of health care to low-income Americans remains an ongoing policy challenge. In this paper, I examine how important changes to occupational licensing laws for nurse practitioners and physician assistants have affected cost and intensity of health care for Medicaid patients. The results suggest that allowing physician assistants to prescribe controlled substances is associated with a substantial (more than 11%) reduction in the dollar amount of outpatient claims per Medicaid recipient. I find little evidence that expanded scope of practice has affected proxies for care intensity such as total claims and total care days. Relaxing occupational licensing requirements by broadening the scope of practice for healthcare providers may represent a low-cost alternative to providing quality care to America's poor.

Adolescent mental health as a risk factor for adolescent smoking onset.

Smoking continues to be a leading cause of preventable deaths and rates of trying cigarettes and progression to daily smoking among adolescents continues to remain high. A plethora of risk factors for smoking among adolescents has been addressed in the research literature. One that is gaining particular interest is the relationship between adolescent mental health and smoking (both initiation and progression). This paper reviews the evidence for adolescent mental health as a risk factor for cigarette smoking. We focus on the specific mental health conditions that have been more thoroughly addressed as possible risk factors in community-dwelling adolescents. We discuss the multiple hypotheses that have been posited as to the nature of the relationship between adolescent mental health and smoking, as well as detailing so called third factors that may account for the observed relationship. We highlight the contribution of the existing studies to the body of knowledge on this topic, as well as the limitations and open questions that remain as a result. We conclude with discussion of a broad research agenda going forward.