Assessing the Role of Nurse Practitioner in Primary Care of Older Adults

 描述(由申请人提供)：随着初级保健医生(MD)的日益短缺，执业护士(NPs)填补了提供初级保健的空白。在我们资助的头三年里，我们发现从非营利组织获得护理的老年人数量在1998至2010年间增长了15倍，从非营利组织获得初级保健的情况在各州之间存在很大差异。我们还观察到，国家对NP实践的规定与从NPs获得初级保健的患者的百分比之间存在很强的关联。在社区糖尿病患者中，使用潜在可预防的住院时间作为质量指标来比较由非营利机构提供的初级保健和由MD提供的初级保健，我们发现非营利机构提供的初级保健至少与初级保健医生提供的初级保健相当。从最初的资助期开始的分析侧重于患者完全从非营利组织接受初级保健，而不是完全从MD接受初级护理。现在，我们希望将注意力转向由两个学科在共享护理模式下护理的患者。由NPS和MD组成的跨学科团队护理已被宣传为新的医疗保健计划(例如，责任护理组织(ACO))和根据《平价医疗法案》(ACA)建立的支付模式成功的关键。随机临床试验(RCT)表明，跨学科团队护理改善了护理过程和结果，特别是对于患有复杂医疗条件的患者，这些患者需要协调与不同医疗保健提供者的多次接触。然而，这些模式如何在更多样化的患者群体和临床环境中运作尚不清楚。我们建议的更新研究将解决这一关键的知识差距问题，这是第一次对在现实世界中为患者提供初级护理的跨学科团队模式进行的全国性人口调查。我们将重点检查团队初级保健模式，并评估与这些模式相关的因素和结果，适用于患有慢性病(糖尿病、充血性心力衰竭和慢性阻塞性肺疾病)的患者。本研究的具体目的是：1.利用社会网络分析方法识别和表征不同的团队护理模式；2.从NP-MD团队护理模式中确定与接受护理相关的患者、地区和卫生系统因素；3.与仅涉及初级保健医生的传统模式相比，检验NP-MD团队护理模式提供的护理过程、结果和成本。为了实现这些目标，我们将使用2013年至2016年医疗保险受益人的全国样本中的索赔来进行这项比较有效性研究。

 DESCRIPTION (provided by applicant): With the increasing shortage of primary care physicians (MDs), nurse practitioners (NPs) have filled the gap in providing primary care. In our first three years of funding, we found that the number of older adults receiving care from NPs grew fifteen-fold between 1998 and 2010, and that there was substantial variation in the receipt of primary care from NPs across states. We also observed a strong association between state regulations of NP practice and the percent of patients receiving their primary care from NPs. Using potentially preventable hospitalization as a quality indicator to compare primary care delivered solely by NPs to care delivered by MDs in community dwelling patients with diabetes, we found that primary care provided by NPs was at least comparable to that provided by primary care physicians. The analyses from this initial funding period have focused on patients receiving their primary care exclusively from NPs vs. exclusively from MDs. We now wish to turn our attention to patients cared for by both disciplines in a shared care model. Interdisciplinary team care- comprised of NPs and MDs- has been promoted as a key to the success of new healthcare programs (e.g., Accountable Care Organizations (ACOs)) and payment models established under the Affordable Care Act (ACA). Randomized clinical trials (RCTs) have shown that the interdisciplinary team care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care for multiple encounters with various health care providers. How these models operate in more diverse patient populations and clinical settings, however, is unknown. Our proposed renewal study-the first national population-based investigation of interdisciplinary team models providing primary care in real-world patients- will address this critical gap in knowledge. We will focus on examining team primary care models and assessing the factors and outcomes associated with such models, in patients with chronic conditions (diabetes, congestive heart failure, and chronic obstructive pulmonary disease). The specific aims are to: 1. Identify and characterize different team care models involving NPs and primary care physicians using social network analysis; 2. Determine patient, regional and health system factors associated with receiving care from NP-MD team care models; and 3. Examine the processes, outcomes and cost of care provided by NP-MD team care models compared with the traditional model involving primary care physicians only. To address these aims, we will use claims from national samples of Medicare beneficiaries from 2013 through 2016 to conduct this comparative effectiveness research.