Addressing Psychiatrist Workforce Shortages in the U.S. with Psychiatric Advanced Practice Registered Nurses

解决精神科医生劳动力短缺在美国与精神病学先进的做法 注册护士（APRN） 项目总结/摘要 美国正经历着严重的精神科医生短缺，这极大地限制了获得行为 健康（BH）治疗许多人，包括一些最脆弱的严重和持续的 精神疾病（SPMI）。虽然精神科高级执业注册护士（APRN）是唯一合格的 为了缓解BH处方医生短缺的问题，有几个障碍限制了他们最大限度地实践的能力 他们的执照和培训程度。尽管APRN在美国各州都有规定性的权力， 他们的处方管理必须由医生监督，各州情况各不相同。截至2016年，只有22个州 和DC允许APRN之间完全独立的规定权，而其余28个州则限制 他们的处方自主权。这些以州为基础的规定经常被认为是充分利用 精神病APRN过去为扩大APRN的规范权力范围所作的努力遇到了重大困难， 医生和著名的专业组织以病人安全问题为由反对。有 还担心扩大APRN的规定权不会导致任何整体净增加， 因为APRN处方只会取代或“排挤”医生处方。 这项拟议中的研究将是第一个利用正在进行的自然实验来为政策辩论提供信息的研究 围绕着扩大APRN的规范权威，作为解决重大问题的一种方法， 美国精神科医生处方劳动力短缺。拟议的项目将使用50个州的医疗补助计划。 2010-2013年的分析eXtracts和相关医疗保险D部分数据，以评估BH的处方（即， 抗精神病药、情绪稳定剂、抗抑郁药和酒精使用障碍）药物 使用SPMI（即，精神分裂症谱系障碍，双相情感障碍，重性抑郁症，合并饮酒 精神病APRN和精神科医生。倾向分数匹配将是主要机制 以控制选择偏倚，将使用广义线性混合模型分析倾向评分- 匹配的数据集，以解决以下具体目标：（1）比较指南一致的处方 接受以下治疗的SPMI患者的BH药物和治疗连续性（依从性、持续性） 精神科APRN与精神科医生;（2）确定允许APRN处方的状态的影响 自主地开具与指南一致的BH药物处方和治疗连续性（依从性， 持续性）。作为一个额外的目标，我们将利用最近的变化， 马里兰州的规定性权威法规，以评估是否允许精神病APRN处方 与其他州相比，自主导致SPMI的BH药物处方净增加 在APRN有独立的实践但没有规定权威的情况下：（3）调查国家的影响 允许APRN根据BH药物对SMI患者的总体可用性自主开处方 以及排挤精神科医生的处方。

Addressing Psychiatrist Workforce Shortages in the U.S. with Psychiatric Advanced Practice Registered Nurses (APRNs) Project Summary/Abstract The U.S. is experiencing a severe shortage of psychiatrists, which greatly limits access to behavioral health (BH) treatments for many individuals, including some of the most vulnerable with serious and persistent mental illnesses (SPMI). While psychiatric advanced practice registered nurses (APRNs) are uniquely qualified to alleviate BH prescriber shortages, there are several barriers that limit their ability to practice to the fullest extent of their licensure and training. Although APRNs have prescriptive authority in all U.S. states, whether their prescriptive management must be supervised by a physician varies by state. As of 2016, only 22 states and DC allow for fully independent prescriptive authority among APRNs while the remaining 28 states restrict their prescribing autonomy. These state-based regulations are frequently cited as barriers to full utilization of psychiatric APRNs. Past efforts to expand the scope of APRNs’ prescriptive authority have met with significant opposition by physicians and prominent professional organizations who cite patient safety concerns. There are also concerns that expanding APRNs’ prescriptive authority does not result in any overall net increase in the availability of medications, because APRN prescribing will merely replace or “crowd out” physician prescribing. The proposed study will be the first to capitalize on an ongoing natural experiment to inform the policy debate surrounding the expansion of APRNs’ prescriptive authority as one approach to addressing the significant psychiatrist-prescriber workforce shortage in the U.S. The proposed project will use the 50-state Medicaid Analytic eXtracts and related Medicare Part D data from 2010-2013 to evaluate prescribing of BH (i.e., antipsychotic, mood stabilizer, antidepressant, and alcohol use disorder) medications in Medicaid enrollees with SPMI (i.e., schizophrenia spectrum disorders, bipolar disorder, major depression, co-occurring alcohol use disorders) by psychiatric APRNs and psychiatrists. Propensity score matching will be the primary mechanism to control for selection bias, and generalized linear mixed models will be used to analyze the propensity score- matched datasets to address the following specific aims: (1) To compare prescription of guideline-concordant BH medications and treatment continuity (adherence, persistence) among patients with SPMI treated by psychiatric APRNs versus psychiatrists; (2) To determine the effects of states permitting APRNs to prescribe autonomously on prescription of guideline-concordant BH medications and treatment continuity (adherence, persistence) among patients with SPMI. As an additional aim, we will leverage recent changes in state prescriptive authority regulations in Maryland to evaluate whether allowing psychiatric APRNs to prescribe autonomously has led to a net increase in prescriptions for BH medications for SPMI compared to other states where APRNs have independent practice but not prescriptive authority: (3) To investigate the effects of states permitting APRNs to prescribe autonomously on the overall availability of BH medications to patients with SMI and on crowding-out psychiatrist prescribing.