Nurse Practitioners and Physician Assistants: Primary Care Roles and Outcomes

执业护士和医师助理：初级保健的角色和结果

• 批准号: 8676365
• 负责人: George L. Jackson
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-07-01 至 2017-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8676365
• 关键词: Accident and Emergency department; Address; Admission activity; Adopted; Affect; Ambulatory Care; Blood Pressure; Caring; Characteristics; Chronic; Chronic Care; Chronic Disease; Clinic; Clinical; Clinical Skills; Complex; Cross-Sectional Studies; Data; Data Set; Diabetes Mellitus; Diagnosis; Evaluation; Future; Glycosylated hemoglobin A; Health; Health Resources; Health Services Accessibility; Health Status; Health Surveys; Healthcare; Healthcare Systems; Home environment; Inpatients; Knowledge; LDL Cholesterol Lipoproteins; Linear Models; Measures; Medical; Medical center; Medicare; Methods; Modeling; Nurse Practitioners; Ophthalmic examination and evaluation; Outcome; Patient Care; Patients; Pattern; Physician Assistants; Physician' s Role; Physicians; Primary Care Physician; Primary Health Care; Process; Process Measure; Provider; Quality of Care; Research; Role; Rural; Self Management; Services; Socioeconomic Status; Solutions; Surveys; Tracer; Variant; Veterans; Visit; Weight maintenance regimen; Work; base; care delivery; comparative; cost; demographics; diabetic; disorder control; economic outcome; health administration; health care service utilization; novel strategies; patient oriented; programs; skills; treatment as usual

Anticipated Impact on Veterans' Healthcare: This project will describe and compare outcomes of Veterans Health Administration (VHA) nurse practitioner (NP), physician assistant (PA), and physician roles in primary care of patients with diabetes. Results will inform patient aligned care team (PACT) role implementation so that NPs and PAs can maximally contribute to quality and cost of veteran care. For example, results will compare NP, PA, and physician care outcomes for clinically complex patients. Intermediate study results, such as how number and type of patient visits correlate with assigned primary care provider, can rapidly aid VHA workforce planning and evaluation. The project expands methods for characterizing VHA NP and PA roles utilizing secondary data that can be adapted for future VHA research addressing how to best utilize NP and PA skills. Background: Expected primary care provider shortfalls threaten access to care in both the Veterans Health Administration (VHA) and the U.S. healthcare system. Meanwhile, deficiencies in quality and efficiency of primary care demand new approaches such as patient-aligned care team models. Expanded use of NPs and PAs is key to addressing these access, quality, and cost issues. Although the VHA has been a pioneer in adopting expansive roles for nonphysician providers and VHA PACTs can be led by NPs and PAs, there is limited information about how the work of patient care is divided among VHA providers or about how this division of labor affects care outcomes and costs. Because of potential differences in care provided by NPs and PAs, our study assesses each profession separately. Because most non-VHA national datasets under-represent NP and PA care, the VHA provides the only national data that allow for valid comparisons of care provided by different provider types. Building on our previous work, we will use diabetes as a tracer condition to evaluate care. Diabetes is prevalent (>24% of VA patients) and costly to the VHA, and treatment of patients with diabetes calls for services representative of the wide range of clinical skills and tasks required of primary care providers. Objectives: The project purpose is to examine clinical roles of NPs, PAs, and physicians in VHA primary care of patients with diabetes and to assess the association of these roles with care outcomes and costs. Aim 1. Characterize role patterns for allocation of patient care work among NPs, PAs, and physicians in the care of patients with diabetes in VHA primary care clinics. Aim 2. Compare quality of care outcomes for patients with diabetes across usual provider of care (UPC) types and NP & PA roles, controlling for organizational characteristics and patient health status. We will examine intermediate patient-level clinical outcomes (i.e. hemoglobin A1c, blood pressure, and low- density lipoprotein cholesterol) and patient-level clinical processes that are more proximal to the provider (i.e. receipt of a diabetic eye exam and new participation in the MOVE! Weight Management Program). Aim 3. Evaluate health resource utilization and costs for patients with diabetes across UPC types and NP & PA roles, controlling for initial health and organizational characteristics. We will evaluate utilization of: 1) outpatient care (primary and total); 2) emergency department care; and 3) inpatient care (ambulatory care sensitive condition admissions and total) and total patient-level costs. Methods: This is a retrospective cross-sectional study using secondary VHA data combined with previously collected VHA facility survey data. We will describe the roles of NPs, PAs, and physicians (usual provider vs. supplemental provider; type of care provided, and complexity of patients) by patient and organizational characteristics. We will then utilize hierarchical linear modeling (patients clustered within providers clustered within facilities) to examine the association between provider roles and intermediate clinical, process and economic outcomes, controlling for patient and organizational factors described above.

对退伍军人医疗保健的预期影响：该项目将描述和比较退伍军人的结果 卫生管理局（VHA）护士执业者（NP），医生助理（PA）和医生在主要 糖尿病患者的护理。结果将告知患者调整护理团队（PACT）的角色实施， NP和PA可以最大限度地提高退伍军人护理的质量和成本。例如，结果将比较 临床复杂患者的NP、PA和医生护理结局。中级研究结果，如如何 患者就诊的数量和类型与指定的初级保健提供者相关，可以快速帮助VHA工作人员 规划和评价。该项目扩展了表征VHA NP和PA作用的方法， 二次数据，可以适用于未来的VHA研究解决如何最好地利用NP和PA技能。 背景：预期的初级保健提供者短缺威胁到退伍军人健康和医疗保健的可及性。 VHA和美国医疗保健系统。与此同时，质量和效率的不足， 初级保健需要新的方法，如以病人为中心的护理团队模式。扩大使用NPs， 保护区是解决这些接入、质量和成本问题的关键。 尽管VHA一直是采用非医生提供者和VHA扩展角色的先驱， PACTs可以由NP和PA领导，关于如何划分患者护理工作的信息有限 VHA提供者之间的差异，或者这种分工如何影响护理结果和成本。因为 NPs和PA提供的护理的潜在差异，我们的研究分别评估了每个职业。 由于大多数非VHA国家数据集代表NP和PA护理，VHA提供了唯一的 国家数据，以便对不同类型的提供者提供的护理进行有效的比较。充分发挥两国 以前的工作，我们将使用糖尿病作为示踪条件，以评估护理。糖尿病很普遍（> VA的24% 患者）和昂贵的VHA，和治疗糖尿病患者要求的服务代表 初级保健提供者所需的广泛的临床技能和任务。 目的：该项目的目的是检查NPs、PA和医生在VHA初级中的临床角色 糖尿病患者的护理，并评估这些角色与护理结果和成本的关联。 目标1.描述NP、PA和医生之间分配患者护理工作的角色模式 在VHA初级保健诊所护理糖尿病患者。 目标2.比较糖尿病患者在常规护理提供者中的护理质量结局 (UPC)类型和NP & PA角色，控制组织特征和患者健康状况。 我们将检查中间患者水平的临床结局（即血红蛋白A1 c、血压和低血糖）。 密度脂蛋白胆固醇）和更接近提供者的患者水平的临床过程（即， 接受糖尿病眼科检查并重新参与MOVE！体重管理计划）。 目标3.评估不同UPC类型糖尿病患者的卫生资源利用和成本， NP & PA角色，控制初始运行状况和组织特征。我们将评估 利用：1）门诊护理（初级和全部）; 2）急诊科护理; 3）住院护理 （门诊护理敏感条件入院和总）和总患者水平的成本。 方法：这是一项回顾性横断面研究，使用二级VHA数据结合先前的 收集VHA设施调查数据。我们将描述NP、PA和医生的角色（通常的提供者与 补充提供者;提供的护理类型和患者的复杂性） 特色然后，我们将利用分层线性建模（患者聚集在提供者中， 在设施内）检查提供者角色与中间临床、过程和 经济结果，控制上述患者和组织因素。

项目成果

Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus.

与拥有医师、执业护士或医师助理作为患有糖尿病的退伍军人的初级保健提供者相关的因素。

• DOI: 10.1177/0046958017712762
• 发表时间: 2017
• 期刊: Inquiry : a journal of medical care organization, provision and financing
• 作者: Morgan,Perri;Everett,ChristineM;Smith,ValerieA;Woolson,Sandra;Edelman,David;Hendrix,CristinaC;Berkowitz,TheodoreSZ;White,Brandolyn;Jackson,GeorgeL
• 通讯作者: Jackson,GeorgeL