Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician's Assistants

Department of Biostatistics, UMDNJ-School of Public Health, Piscataway, New Jersey 08854, USA.
The Annals of Family Medicine (Impact Factor: 5.43). 01/2008; 6(1):14-22. DOI: 10.1370/afm.758
Source: PubMed


The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care.
This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.
Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A(1c) levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P <or= .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A(1c) levels (66% vs 49%) and lipid levels (80% vs 68%) (P<or=.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.
Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.

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Available from: Bijal A Balasubramanian, Oct 04, 2015
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    • "training and quality improvement interventions in order to eradicate or at least minimize the effects of these factors [35]. The level of optimal use of screening in this report of 1%, was much lower than that noted in other studies [36] [37] [38]. "
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    ABSTRACT: Objectives: In the present study, the audit of medical files of patients with diabetes, followed in family medicine practices in the eastern region of Bosnia and Herzegovina (BiH), was carried out in order to investigate the frequency of the use of screening tests for early diagnosis of diabetes complications. Methods: The audit was conducted in 32 family medicine practices from 12 primary health care centers in the eastern part of BiH over one-year period (March 2010 to March 2011). A specially established audit team randomly selected medical files of 20 patients with diabetes from the Diabetes Registry administered by each family medicine team database. Screening tests assessed are selected according to the ADA guidelines. Results: Frequency of the individual screening test varied between 99%, found for at least one blood pressure measurement, and 3.8% for ABI measurement. When the frequency of optimal use of screening was analyzed, only 1% of patients received all recommended screening tests. Conclusion: The frequency of the use of screening tests for chronic diabetes complications was found to be low in the eastern part of Bosnia and Herzegovina. Multivariate linear regression analysis showed that longer duration of diabetes and a larger number of diabetics per practice were associated with a smaller number of screening tests, but specialists in family medicine provided a higher number of screening tests compared to other physicians.
    Primary Care Diabetes 06/2014; DOI:10.1016/j.pcd.2014.05.006 · 1.33 Impact Factor
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    • "The positive findings are however not universal, with poor documentation of history and physical examination reported at a remote clinic in the 1970s [60], and with PAs being rated less favourably on all measures to monitor patients with diabetes and their patients less likely to achieve targets for disease control in 2002 [79]. "
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    ABSTRACT: Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems. Medline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. Eligibility criteria: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care. 2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. Process: the majority of PAs’ workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. Outcomes: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time. Limitations: identification of a broad range of studies examining ‘contribution’ made meta analysis or meta synthesis untenable. The research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs’ contribution to the international primary care workforce.
    BMC Health Services Research 06/2013; 13(1):223. DOI:10.1186/1472-6963-13-223 · 1.71 Impact Factor
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    • "As the US primary care system confronts provider shortfalls due to demographic trends, the growing prevalence of chronic disease [4], and low proportions of physicians choosing primary care practice [5], a possible solution is expanded use of physician assistants (PAs) and nurse practitioners (NPs) [6]. 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]. "
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    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. Methods 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). Results 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. Conclusions 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
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