PAs and NPs reduce nursing home resident readmission rates
About one-fifth of hospitalized Medicare beneficiaries are discharged to long-term care facilities for postacute care. Readmissions are common but interventions to reduce readmissions are scarce. Using a retrospective cohort design, the authors investigated the effect of a connected care model on 30-day hospital readmission rates among patients discharged to long-term care facilities. All patients admitted to the Cleveland Clinic main campus between 2011 and 2014 and subsequently discharged to seven intervention long-term care facilities or 103 control long-term care facilities were included in the study. Hospital-employed physicians and PAs or NPs visited patients four to five times per week. During the intervention phase (2013-2014), adjusted 30-day readmission rates declined at the intervention long-term care facilities (28.1% to 21.7%, P < .001) and increased slightly at control long-term care facilities (27.1 % to 28.5%, P < .001). The absolute reductions ranged from 4.6% for patients at low risk for readmission to 9.1% for patients at high risk, and medical patients benefited more than surgical patients. A program of frequent visits by hospital-employed physicians and PA or NPs at long-term care facilities can reduce 30-day readmission rates.1
Commentary by Benjamin J. Smith: Strategies to reduce readmission after hospital discharge are crucial to delivering high-quality care in the most cost-effective manner. Although conducted in one hospital network, this study demonstrates the value of PAs and NPs and their role facilitating a patient's transition from hospital discharge to returning to optimal outpatient quality of life. The authors suggest a long-term care intervention in which PAs see the admitted patients four to five times each week; coordinating with a multidisciplinary team reduces hospital readmissions regardless of the patient's risk of readmission per the patient's calculated HOSPITAL score.2,3 Activities within the first 48 hours after hospital discharge are key to ensure correct communication about medication regimens and assessments have occurred between the hospital and long-term care facility. PAs are well prepared based on their formal training and usefulness in medical settings to directly reduce hospital readmissions by described interventions in the long-term care setting. Because the authors state that medical patients benefited more from this long-term care intervention than surgical patients, additional research is warranted, including how PAs can improve desired outcomes for all patients.
1. Kim LD, Kou L, Hu B, et al Impact of a connected care model on 30-day readmission rates from skilled nursing facilities. J Hosp Med. 2017;12(4):238–244.
2. Donzé J, Aujesky D, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Intern Med. 2013;173(8):632–638.
3. Donzé JD, Williams MV, Robinson EJ, et al International validity of the HOSPITAL score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016;176(4):496–502.
Nurses as substitutes for physicians in primary care
Substituting nurses for physicians is one strategy used to improve access, efficiency, and quality of care. Eighteen randomized trials evaluating the outcomes of nurses working as substitutes for physicians were weighted and assessed. Study findings suggest that care delivered by nurses, compared with physicians, probably generates similar or better healthcare outcomes for a broad range of patient conditions: Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared with physician-led care. BP outcomes are slightly improved in nurse-led primary care. Other clinical or healthcare status outcomes probably are similar. Patient satisfaction is slightly higher in nurse-led primary care and quality of life may be slightly higher. Little or no difference was found between nurses and physicians in the number of prescriptions and attendance at accident and emergency units. There may be little or no difference in the number of tests and investigations, hospital referrals, and hospital admissions between nurses and physicians. This meta-analysis showed that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as NPs and RNs, probably provide equal or possibly even better quality of care compared with primary care physicians, and probably achieve equal or better healthcare outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared with primary care doctors. Other use outcomes probably are the same.1
Commentary by Roderick S. Hooker: This is an update of the Cochrane review on the question of physician substitution that was first published in 2005. Since that review, more than 30 studies on NP (or NP and physician assistant [PA]) versus physician care have been published. In that same period, the quality of research on physician substitution has grown and the geographic distribution has spread from the United States to a dozen other countries. Physician substitution is a disruptive movement, like ridesharing apps are to city-regulated taxis service. Less structured but more available, physician substitutes are convenient, reliable, less expensive, and more reflective of the community from whence they came. More people are served with the same outcomes and satisfaction of service is higher. The first author of this study is a leading authority on physician substitution and her team of coauthors is without peers. As for the publication, healthcare professionals, patients, and policy makers formed the Cochrane organization in 1993 to organize medical research findings and facilitate choices about health interventions. Cochrane consists of 53 review groups that are based at research institutions worldwide.
1. Laurant M, van der Biezen M, Wijers N, et al Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev. 2018;7:CD001271.
Removing anticompetitive barriers for APRNs and PAs
Important productivity gains could be achieved by altering the mix of labor inputs (clinicians) used in the healthcare sector. However, the potential for these gains is sharply limited by anticompetitive policy barriers in the form of restrictive scope of practice laws imposed on PAs and APRNs. This proposal discusses evidence that shows how these laws restrict competition, generate administrative burdens, contribute to increased healthcare costs, and create no discernable health benefits. The proposal also discusses how moving to a fully authorized scope of practice for PAs and APRNs could free up labor markets, allowing for a more cost-effective and more productive use of clinicians, while potentially fostering innovation and still protecting public health. A key outcome would be improved access as gains in productivity increase capacity in the healthcare system. The proposal concludes by discussing state and federal policies that either remove these barriers directly or encourage state legislative bodies to do so.1
Commentary by Benjamin McMichael: Focusing on scope of practice laws, the authors offer a well-reasoned proposal for changing how states regulate PAs and APRNs. Among other changes, the proposal calls for eliminating legal requirements that APRNs maintain supervisory arrangements with physicians and allowing the level of interaction between PAs and physicians to be determined at the practice level. However, the authors state that policy makers should encourage collaborative relationships between APRNs, PAs, and physicians because these already are the norm in these professions. Though the proposal is somewhat modest in its departure from existing laws, this may be a strength, as policy makers of different political alignments may find it easier to support than more far-reaching legal changes. In support of their proposal, the authors provide a thorough review of the scope of practice law literature focusing on the role these laws play in the operation of the healthcare workforce, delivery of care, and access to care. Although this review is useful, the authors' most important contribution beyond the proposal itself may be their extensive discussion of how various state and federal laws interact with scope of practice laws in subtle but critically important ways.
Adams EK, Markowitz S. Improving Efficiency in the Health-Care System: Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants. The Hamilton Project. June 2018.
Primary care physician practices increasingly rely on NPs and PAs
The use of NPs in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. The study authors found increasing NP presence in rural and nonrural primary care practices from 2008 to 2016. At the end of the period, NPs constituted 25.2% of providers in rural and 23% in nonrural practices, compared with 17.6% and 15.9%, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers who can strengthen healthcare delivery.1
Commentary by Edward Salsberg: Making creative use of a nonpublic source of data on staffing in physician primary care practices (SK&A, now IQVIA), the authors document the recent, continued rapid growth in the number of practicing NPs and PAs. Although the focus is on NPs, the paper also includes some data on the growth of PAs in primary care. The bottom line is that NPs and PAs made up nearly 40% of the clinical staff in rural primary care practices (physicians were the other 60%) in 2016, up from 31% just 8 years earlier. NPs and PAs accounted for 35% of clinicians in primary care practices in nonrural areas, up from 25% in 2008. This rapid growth will undoubtedly continue given the sharp increase in the number of graduates from NP and PA programs.2 Barnes and colleagues found strong rates of NP growth regardless of state statutes on NP scope of practice and whether states expanded Medicaid. The reality is that NPs and PAs are widely accepted by physicians and patients and they will be an even greater proportion of providers in the future. This is a positive development, which will increase access to care in a cost-effective manner. It should also reduce worries about a physician shortage in the future.
1. Barnes H, Richards MR, McHugh MD, Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners. Health Aff (Millwood). 2018;37(6):908–914.
Salsberg E. Changes in the pipeline of new NPs and RNs: implications for health care delivery and educational capacity. Health Affairs blog, June 5, 2018. http://www.healthaffairs.org/do/10.1377/hblog20180524.993081/full. Accessed October 23, 2018.
What makes PA training programs successful at training rural PAs?
The proportion of PAs practicing rural primary care has declined over the past 3 decades. The survey results from 173 PA programs identified program characteristics that facilitate rural PA practice. Programs were categorized as rurally oriented or nonrurally oriented, and as high rural producing or lower rural producing. Rurally oriented programs recruited more rural students, used rural background as an admissions criterion, included rural issues in their didactic curriculum, and required rural clinical rotations more often than the nonrurally oriented programs. The high rural producing programs recruited more rural students and integrated rural issues into the curriculum more often than the lower rural producing programs. The authors suggest that rural mission statements alone are insufficient. Programs wishing to produce more rurally practicing PAs should modify their admissions practices, enhance their curriculum, and require rural supervised clinical practice experiences.1
Commentary by J. Glenn Forister: Healthcare workforce shortages disproportionally affect rural communities. This policy brief highlights some actions programs can take to meet their stated goal of producing rural PAs. The investigators linked their survey data to a previous study identifying the high-producing programs and categorized 50% of the rurally oriented programs as lower producing, and reduced their sample by 25%. Some limitations include lack of information about the geospatial location of programs, the acceptance rate of rural applicants, the number of available rural rotations, and the availability of scholarship and loan repayment programs for rurally practicing graduates. Although program practices can influence the supply of PAs interested in rural practice, many demand factors may limit a programs rural productivity. Regional differences in the availability of rural PA positions and state laws allowing NP autonomy are known to influence the regional provider mix. Telehealth and remote monitoring programs are emerging, rural hospitals are closing, and healthcare systems are consolidating. How these changes will eventually affect rural PA practices is unclear.
Larson E, Coulthard C, Andrilla C. What makes physician assistant (PA) training programs successful at training rural PAs? WWHAMI Rural Health Research Center Policy Brief #164, 2018.