Supply of providers by socioeconomic status and health
To identify active providers, those listed in the 2014 National Plan and Provider Enumeration System to Medicare claims were linked. Using practice location and specialty code, the total number of adult primary care physicians (internal medicine, family medicine, and general practice), NPs, and PAs in each US county were identified. Data on county characteristics were gathered from the 2010 US Census, and the presence of a hospital was identified using the Area Health Resource File. Adjusted for county-level differences, the supply of primary care physicians increased across socioeconomic status (P-trend = 0.01). For instance, the number of primary care physicians was 31% higher in the highest income quartile than in the lowest (RR = 1.31 [95% CI: 1.15, 1.48]). The distribution of PAs exhibited a pattern similar to that of primary care physicians. Policies for enhancing access to care for underserved communities should incorporate incentives to encourage providers to locate in areas of greatest need.1
Commentary by Walt Eisenhauer: This research provides a unique mechanism to assess the current system's ability to meet the healthcare needs of rural and underserved populations. The conclusion that a correlation exists between socioeconomic status of a community and the deployment of various primary care provider types is consistent with historic trends. Maldistribution of providers in areas that serve economically disadvantaged populations represents one of the driving forces that precipitated the development of both PA and NP models. One might conclude that NPs have been more successful due to the independent nature of their practice. However, as providers are increasingly employees of large systems, and in light of a corporatized healthcare reimbursement system that is increasingly dependent on volume to maintain operating margins, service becomes secondary to maintaining financial viability. Proposed solutions might include a significant differential in reimbursement for rural and underserved communities or a centralized reimbursement model tasked with assuring primary care access equitably to all socioeconomic classes and geographic regions.
1. Davis MA, Anthopolos R, Tootoo J, et al Supply of healthcare providers in relation to county socioeconomic and health status. J Gen Intern Med. 2018;33(4):412–414.
Task shifting between physicians and nurses in acute care hospitals
Countries vary in the extent to which they expand scope of practice for advanced practice registered nurses (APRNs). This study analyzed physicians' and APRNs' perceptions of role change and task shifting in nine European countries after APRN scope-of-practice reform. The design was cross-sectional using surveys completed by 1,716 providers treating patients with breast cancer and acute myocardial infarction (AMI) in 161 hospitals. Analyses included descriptions of staff role changes in two country groups: 1) major scope-of-practice reforms (Netherlands, England, Scotland) and 2) no scope-of-practice reform (Czech Republic, Germany, Italy, Norway, Poland, Turkey). From 2010 to 2015, healthcare providers in the first group reported greater provider role changes compared with providers in the second group (breast cancer, 74% versus 38.7%; AMI, 61.7% versus 37.3%), as well as higher independence for APNs (breast cancer, 58.6% versus 24%; AMI, 48.9% versus 29.2%). Although a higher proportion of APNs from countries with major scope-of-practice reform reported increasingly undertaking more care tasks, most care was performed by both physicians and APNs rather than carried out by one profession. These results suggest that professional boundaries have shifted, but care is still delivered by interdisciplinary groups of providers.1
Commentary by Hilary Barnes: Population changes and policy reform have led to growing patient demand and changes in how healthcare is delivered in the United States. Evolving models of care are increasingly incorporating PAs and NPs, and there is support for full use of these providers in ambulatory settings to mitigate provider shortage concerns and improve patient outcomes.2,3 What this study contributes, however, is new insight and evidence of the growing role of NPs and PAs in hospital-based care.1 The authors show that in countries that favorably reformed PA or NP scope of practice, many care tasks were shifted to PAs and NPs, while others continued to be provided by all three clinician types—potentially reflecting an increase in the use of interdisciplinary, team-based care. This study was conducted in the European Union but the results are relevant to the US healthcare system. At a time when hospitals are seeking ways to improve safety, reduce readmissions, and lower costs, incorporating PAs and NPs into care teams and letting them practice to the top of their education and training is a means to optimize the workforce for the delivery of high-quality and efficient care in hospitals. This will be especially important as value-based payment models become universal.
1. Maier CB, Köppen J, Busse R, MUNROS team. Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries. Hum Resour Health. 2018;16(1):24.
US Department of Health and Human Services. Health Resources and Services Administration. National Center for Health Workforce Analysis. Projecting the supply and demand for primary care practitioners through 2020. https://bhw.hrsa.gov/health-workforce-analysis/primary-care-2020. Accessed February 25, 2019.
3. Everett C, Thorpe C, Palta M, et al Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes. Health Aff (Millwood). 2013;32(11):1942–1948.
ICU staffing of PAs and NPs in the Netherlands
Literature in Europe about implementing NPs or PAs in ICU is lacking, although some available studies indicate that this concept can improve the quality of care and overcome physician shortages in ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented PAs and NPs, as well as residents, and what this staffing model adds to the care on the ICU. This paper defines the training course and job description of NPs and PAs in a Dutch ICU. It describes the number and quality of invasive interventions performed by PAs, NPs, residents, and intensivists during 2015 and 2016. Salary scales of PAs and NPs and residents are provided to describe potential cost-effectiveness. The tasks of PAs and NPs in the ICU are equal to those of the residents. Analysis of the invasive interventions performed by PAs and NPs showed an incidence of central venous catheter insertion of 20 per full-time equivalent (FTE) compared with 4.3 per FTE for residents in 1 year. For arterial catheters, PAs and NPs inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding salary, after 5 years in service an NP or PA earned more than a starting resident. This is the first European study that describes the role of PAs and NPs in the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by PAs and NPs.1
Commentary by Harrison Reed: Although this article describes Dutch PAs and NPs in ICUs, the training program and clinical role will be anything but foreign to many US observers. The authors present PAs and NPs as analogous to resident physicians, a designation that might be a compliment for some PAs and an insult to others. In comparing PAs, NPs, and residents, the authors focus on procedural skills and complication rates rather than more holistic outcomes. Although procedural prowess is a selling point of PAs in critical care, the decision to highlight technical skills rather than true clinical decision-making may represent a missed opportunity. After all, Dutch PAs in critical care have proven their broader clinical skills in a head-to-head comparison with residents in the simulation laboratory.2 Distilling the benefit of these clinicians to technical tasks begs the question: are Dutch ICUs—and some of their US counterparts—missing out on the real value of PAs and NPs? Of course, cost-effectiveness is relative. The PAs and NPs presented in this article earn a much lower salary than their colleagues in the United States, making it unlikely that PAs from the United States will flock to the Netherlands, no matter how pretty the tulips.
1. Kreeftenberg HG, Aarts JT, de Bie A, et al An alternative ICU staffing model: implementation of the non-physician provider. Neth J Med. 2018;76(4):176–183.
2. van Vught AJAH, van den Brink GTWJ, Hilkens MGEC, van Oers JAH. Analysis of the level of clinical skills of physician assistants tested with simulated intensive care patients. J Eval Clin Pract. 2018;24(3):580–584.
Can we really reduce burnout without reducing the workload?
Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, the extent to which delegation occurs within multidisciplinary teams, factors associated with greater delegation, and whether delegation is associated with burnout are unknown. The authors performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to 15 survey questions relating to delegated tasks. Next, the researchers performed multivariable regression to explore predictors of task delegation and burnout. Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on. About 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout; nurses who reported being relied on more reported more burnout. Strategies to improve work life in primary care by increasing PCP task delegation must take into account the effect on nurses.1
Commentary by Bettie Coplan: This cross-sectional study of VA primary care teams revealed that PCP (physician, NP, or PA) task delegation to nurses was associated with less burnout for providers but more burnout for nurses. In other words, shifting the work may merely shift the burnout. Although factors related to how healthcare professionals work, for example—with little autonomy, a lack of social support, or in teams with poor leadership—are known to contribute to burnout, workload alone has a significant effect.2-5 Tasks that are perceived as unrewarding, such as the administrative aspects of healthcare delivery that have increased with the computerization of order entry and documentation, particularly affect job satisfaction.5 Despite lofty goals to shift the focus of healthcare from quantity to quality, fee-for-service payment methods continue to dominate.6 Research suggests that work demands on healthcare professionals are associated with burnout period.3,5 Although efficient team processes, such as appropriate task delegation, certainly have the potential to improve job satisfaction, relying on team members to reduce burnout may be a solution for some that simply shifts the burden to others.7
1. Edwards ST, Helfrich CD, Grembowski D, et al Task delegation and burnout trade-offs among primary care providers and nurses in veterans affairs patient aligned care teams (VA PACTs). J Am Board Fam Med. 2018;31(1):83–93.
2. Spence Laschinger HK, Leiter M, Day A, Gilin D. Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcomes. J Nurs Manag. 2009;17(3):302–311.
Dyrbye LN, Shanafelt TD, Sinsky CA, et al Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care. Accessed February 25, 2019.
4. Balch CM, Shanafelt TD, Dyrbye L, et al Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg. 2010;211(5):609–619.
5. Shanafelt TD, Dyrbye LN, Sinsky C, et al Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836–848.
6. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff (Millwood). 2016;35(3):411–414.
7. Linzer M, Poplau S, Grossman E, et al A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. J Gen Intern Med. 2015;30(8):1105–1111.