Examine potential associations between inclusion of mid-level providers in United States Veterans Affairs (VA) primary care programs and diabetes control.
We established a cohort of diabetes patients (alive October 1, 1999) using the VA Diabetes Registry and VA corporate databases. 1999 VA Survey of Primary Care Practices data were combined with individual-patient information. We used a two-level hierarchical model to determine the relationship between staffing characteristics and hemoglobin A1c (HbA1c), among 88,682 patients from 198 clinics.
Inclusion of nurse practitioners (NPs) at relatively limited levels (% of all providers who are NPs) in the primary care program was significantly associated with HbA1c lower by 0.31 percentage points (95% CI, -0.50% to -0.12%) compared to programs that did not include NPs. Having some level of NP staffing vs. no NP staffing was associated HbA1c lower by 0.25%. Inclusion of physician assistants (PAs) in primary care programs was generally not associated with a statistically significant difference in HbA1c. The exception is that moderate levels of PA staffing were associated with slightly higher HbA1c [0.18%, 95% CI, 0.02-0.34)].
Diabetes control among primary care patients appeared to benefit from inclusion of NPs, while an analogous association was not found for PAs.
"As the US primary care system confronts provider shortfalls due to demographic trends, the growing prevalence of chronic disease , and low proportions of physicians choosing primary care practice , a possible solution is expanded use of physician assistants (PAs) and nurse practitioners (NPs) . This solution is supported by a large body of research demonstrating high quality of NP and PA care [7,8] and by recent research suggesting that higher proportions of NPs in primary care clinics are associated with improved outcomes among patients with diabetes [9,10]. "
[Show abstract][Hide abstract] ABSTRACT: Background
Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA) has been a frontrunner in the use of nurse practitioners (NPs) and physician assistants (PAs). Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians.
This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician).
NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits.
This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.
Human Resources for Health 11/2012; 10(1):42. DOI:10.1186/1478-4491-10-42 · 1.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Shortages of primary care doctors are occurring globally; one means of meeting this demand has been the use of physician assistants (PAs). Introduced in the United States in the late 1960s to address doctor shortages, the PA movement has grown to over 75,000 providers in 2011 and spread to Australia, Canada, Great Britain, the Netherlands, Germany, Ghana and South Africa. A purposeful literature review was undertaken to assess the contribution of PAs to primary care systems. Contemporary studies suggest that PAs can contribute to the successful attainment of primary care functions, particularly the provision of comprehensive care, accessibility and accountability. Employing PAs seems a reasonable strategy for providing primary care for diverse populations.
Health & Social Care in the Community 08/2011; 20(1):20-31. DOI:10.1111/j.1365-2524.2011.01021.x · 1.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many patients with diabetes do not have access to clinical care or medications, resulting in cases of undiagnosed diabetes or uncontrolled diabetes, especially in patients of low socioeconomic status. Given these considerations, new strategies are needed to control the rampant growth of diabetes and prevent new cases. This article discusses effective strategies for improving the management of diabetes in underserved populations, with special reference to the Juanita J. Craft Diabetes Health and Wellness Institute, a unique partnership between a large, urban integrated health care system, the City of Dallas, and a South Dallas community.
Primary care 06/2012; 39(2):363-79. DOI:10.1016/j.pop.2012.03.008 · 0.74 Impact Factor
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