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Commentaries on health services research

Tanner, Johnna K., MSPAS, PA-C; Evans, Timothy C., MD, PhD, FACP; Bushardt, Reamer L., PharmD, PA-C

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Journal of the American Academy of PAs: June 2014 - Volume 27 - Issue 6 - p 57-58
doi: 10.1097/01.JAA.0000446989.87305.b9
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What military PAs and NPs can teach civilians


The US military health system, which is responsible for providing care to active and retired members of the military and their dependents, faces challenges in delivering cost-effective, high-quality primary care while maintaining a provider workforce capable of meeting both peacetime and wartime needs. The military health system has implemented workforce management strategies to address these challenges, including “medical home” teams for primary care and other strategies that expand the roles of physician assistants (PAs), nurse practitioners (NPs), and medical technicians. Because these workforce strategies have been implemented relatively recently, evidence of their effectiveness is limited. If proven successful, they could serve as models for the civilian sector. However, because the military health service model features a broad mix of provider types, changes to civilian scope-of-practice regulations for PAs and NPs would be necessary before the civilian provider mix could replicate that of the military health system.

Mundell BF, Friedberg MW, Eibner C, Mundell WC. US military primary care: problems, solutions, and implications for civilian medicine. Health Aff (Millwood). 2013;32(11):1949-1955.

The military practice of placing a PA or an NP as the leader of the “medical home” team for primary care services serves as a model for civilian practices. What is buried in this paper is that military PAs and NPs on active duty have independent status and thus are recognized as standalone providers. For this to become a feasible option in the civilian sector, state scope of practice regulations would need to be altered to support more independent practice. Also briefly mentioned in the paper, but of greater importance, is the fact that the military health service can give command directives to all its health personnel for rapid implementation of model systems as well as clinical practice guidelines. Additionally, the robust military electronic medical record system can track adherence to patient practice guidelines as well as a global budget schedule. Therefore, although uniformed PAs and NPs may practice independently, compared with the civilian sector, the military health system contains many more checks and balances for all providers, as well as a centralized control hierarchy and data monitoring processes.

Commentary by Johnna K. Tanner

Changing 50 years of bad habits in diabetes care


This article reviewed diabetes management of several hundred noncritically ill patients in a Scottsdale, Ariz., Mayo Clinic. The patients managed by standard medical teams were compared with those whose care was directed by a specialty trained PA or NP. Despite systemwide staff education and computerized insulin orders with built-in algorithms, patients cared for by the NP or PA directed team were nearly four times more likely to receive a basal-bolus regimen of insulin than patients in the standard care teams. The NP-PA directed team's patients had significantly lower glucose levels in the 24 hours before discharge.

Mackey PA, Boyle ME, Walo PM, et al. Care directed by a specialty-trained nurse practioner or physician assistant can overcome clinical inertia in management of inpatient diabetes. Endocr Pract. 2014;20(2):112-119.

This was a single-center, two-practitioner, retrospective, nonrandomized study with many places in which bias could enter the analysis. Nevertheless, basal-bolus insulin is the preferred treatment for hospitalized patients with diabetes, and is preferred over no treatment, bolus only, basal only, or sliding-scale insulin. And in this study, the patients cared for by a specialty trained PA or NP team were 3.7 times more likely to get a basal-bolus regimen than patients whose care did not involve this team. The problem with sliding-scale insulin is that the insulin delivery is out of phase with the patient's need for insulin. The insulin bolus given at breakfast, for example, is primarily to match the food being eaten at breakfast, not to fix the abnormal blood glucose before breakfast. The authors refer to “clinical inertia” in diabetes care, which can also be called, “I don't know how to do this and don't want to hurt the patient.” A PA or NP skilled in diabetes management can optimize care and in the process may educate not only patients but also other clinicians in their understanding and comfort providing such care.

Commentary byTimothy C. Evans

Family medicine survey on who employs PAs and NPs


The authors set out to determine what physician and area-level characteristics were associated with working with NPs, PAs, or certified nurse-midwives (CNMs) using a convenience sample of physicians. The data were linked to demographic and practice information collected by the American Board of Family Medicine and with provider information supplied from the National Provider Identifier file aggregated at the primary care service area level. Hierarchical logistic regression models were used to determine variables associated with working with NPs, PAs, or CNMs. Of the 3,855 family physicians in our sample, 60% reported routinely working with NPs, PAs, or CNMs. Characteristics positively associated with working with NPs, PAs, or CNMs were providing gynecological care, multispecialty group practice, any rural setting, and higher availability of PAs. Restrictive NP scope of practice laws failed to reach significance. The number of family physicians routinely working with NPs, PAs, and CNMs is increasing, which may allow for improved access to healthcare, particularly in rural areas.

Peterson LE, Phillips RL, Puffer JC, et al. Most family physicians work routinely with nurse practitioners, physician assistants, or certified nurse midwives. J Am Board Fam Med. 2013;26(3):244-245.

The authors discuss the effect of the Affordable Care Act and make two predictions: more newly insured patients and an aging population will increase demand for healthcare services combined with too few primary care physicians to address this demand.1 Because family physicians are the predominant providers of ambulatory care and the most prevalent physician specialty within rural communities, examining a convenience sample of these physicians is warranted. A deeper understanding of the characteristics of family physicians who do engage in collaborative practice with PAs, NPs, or CNMs may help to refocus workforce development strategies to address unmet healthcare needs of the newly insured, older adults, and those living in rural and underserved areas. Inequitable distribution of physicians geographically is not a new problem, and leveraging team-based practice with PAs, NPs, or CNMs is a proven intervention for improving access to care.2 This study suggests that family physicians, especially younger physicians who practice in rural areas, likely do not lose sleep over debates and controversies over the roles of PAs, NPs, and CNMs propagated by some physician and nursing membership organizations. These family physicians and the PAs, NPs, and CNMs collaborating with them might prefer to take care of patients instead of getting caught up in the drama of trying to decide who should be in charge.3,4

Commentary by Reamer L. Bushardt


1. Peterson LE, Blackburn B, Petterson S, et al. Which family physicians work routinely with nurse practitioners, physician assistants or certified nurse midwives. J Rural Health . [e-pub Dec. 15, 2013].

2. Shipman SA, Lan J, Chang CH, Goodman DC. Geographic maldistribution of primary care for children. Pediatrics . 2011;127(1):19–27.

3. Odell E, Kippenbrock T, Buron W, Narcisse MR. Gaps in the primary care of rural and underserved populations: the impact of nurse practitioners in four Mississippi Delta states. J Am Assoc Nurse Pract . 2013;25(12):659–666.

4. Zenzano T, Allan JD, Bigley MB, et al. The roles of healthcare professionals in implementing clinical prevention and population health. Am J Prev Med . 2011;40(2):261–267.

© 2014 American Academy of Physician Assistants.