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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    • "The availability of nonphysician clinicians with expertise in chronic care management and preventive care may impact teamwork and readiness for change. For example , the availability of nurses, social workers, pharmacists, and health educators to primary care team members may improve patient self-management support, consistent delivery of preventive and chronic illness care processes, and management of the complex needs of patients with multiple chronic conditions (Carter et al., 2009; Ohman-Strickland et al., 2008; Vermeire et al., 2005). Little is known, however, about the relation of primary care team structure, including team member availability and access to interdisciplinary team member expertise, on teamwork and organizational outcomes. "
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    ABSTRACT: Background: Early experiences of patient-centered medical home implementation indicate that redesigning primary care is an intensive organizational change that is most effectively undertaken by high-functioning interdisciplinary teams. Team effectiveness research indicates that consistent availability of team members and other aspects of team structure can impact teamwork and organizational outcomes. Methods: We conducted a survey of 766 adult primary care providers and staff in 34 California safety net practices to assess primary care team structure (team size, team member availability, and access to interdisciplinary expertise), teamwork, and readiness for change. We used path models with robust standard errors for clustering of respondents within practices to examine relationships between team member availability and readiness for change. Using path analysis, we examined the extent to which better teamwork mediated relationships between team member availability and readiness for change. Results: We received 628 completed surveys (response rate = 82%). Greater team member availability was associated with greater readiness for change, but the relationship was stronger for staff than for primary care providers. Contrary to our hypothesis, path analyses revealed that the relationship of team member availability and greater readiness for change was only partially mediated (21%) by better teamwork. The direct effect of teamwork on readiness for change is approximately 2.9 times larger than the direct effect of team member availability on greater readiness for change. Conclusions: Ensuring that members perceive that their teammates are routinely available to them may improve readiness for implementing organizational changes like adopting patient-centered medical home models. Given that better teamwork only partially explained the availability-readiness relationship, additional research to identify the mechanisms through which consistent team member availability increases change readiness could lend insight into how to more effectively support clinicians and staff undergoing complex organizational changes.
    Health care management review 01/2016; DOI:10.1097/HMR.0000000000000082 · 1.30 Impact Factor
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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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