Tuesday, March 30, 2010

A Changing Landscape

With the passing of the recent historic health insurance reform, the focus has turned (see here and here and here) to how will the system deal with the influx of approximately 31 million newly insured seeking access to care. All of these articles address the current shortage of primary care physicians in some way and creates a sense of urgency for patients to try and secure one before access becomes crippled (as it has in Massachusetts).

What these articles fail to address is the true potential that NPs and PAs have to pick up this slack. There is this incorrect assumption that NPs, facing the same barriers in primary care, are flocking to lucrative specialties. Fortunately for patients, this is not the case. A recent survey by Advance for Nurse Practitioners, reveals that most of the NPs polled work in predominantly primary care or primary care-type settings. Also a very informal survey of the NPs that I know has a similar result.

So what does all this mean? The good news is that potential solutions already exist to help with this dilemma. I believe that primary care physicians in the trenches largely recognize this and together we are trying to innovate the system and provide high-quality care with the limited resources we have. We are examining new models of delivery and determining how technology can work to our advantage and improve communications among patients and enhance the continuity of care. The bad news of course is that the aforementioned is easier said than done. Opposition to NP directed care and turf concerns are abundant. State laws and regulations regarding NP practice are out-dated, not evidence based and vary from state to state leaving a patchwork of rules and regulations further impeding access.

I remain hopeful that we will slowly improve the system so that these newly insured as well as already insured will have access to high-quality whole-istic care, will take a meaningful and responsible role in their care, thus producing better outcomes than ever before. It will not be easy and it will be with on-going debate but the landscape of health care will be different in the near future than it is today. It has to be.

Tuesday, March 23, 2010

What Impact Will Reform Have On Nurse Practitioner's?

There are so many unknowns regarding both patients and providers with the passing of the recent monumental health care legislation. Thanks to a recent post on AJN's Off the Charts blog, they posted a link to a handy ANA chart comparing both versions of the legislation and what it means for nurses and nurse practitioners.

Of course, this is subject to change somewhat based on the revisions that still need passing however, I would imagine that it will remain pretty close to this.

It appears the biggest factor for NPs is the ability to lead the team of providers in Patient Centered Medical Home demonstration projects.

Stay tuned for more on this white hot topic of reform......

Thursday, March 18, 2010

New Nurse Workforce Data

The US Department of Health and Human Services just released "Initial Findings from the 2008 National Sample Survey of Registered Nurses." There is some valuable and interesting information in the latest report (the last one was done in 2004).

Of note:

  • There were an estimated 3,063,163 living in the US as of March 2008 (of these, 2,596,599 were employed in nursing positions).
  • The average age for all licensed nurses rose from 46.8 to 47 years and employed nurses rose from 45.4 to 45.5.
  • There are 158, 348 identified NPs
  • The number of NPs grew 12.1% over the last 4 years
  • There were an estimated 28,369 RNs with a doctoral degree in 2008. This is an increase of 64.4% since 2000.
  • The workforce is becoming more diverse. 6.6% of nurses are male (a small jump from 5.8%) but a higher percentage of recent graduates were male from previous (4.1 % prior to 1990 vs. 9.6% since 1990).
  • Hispanics are the most rapidly growing group of registered nurses.
These are just a few highlights from the report. I highly recommend that you review the report to review the data. It is important to recognize and understand the composition of the largest collective group of health care providers in the U.S. After all, these individuals will be among those caring for America.

Thursday, March 11, 2010

I Took the Bait

I have tried to refrain from taking the bait from some recent negative opinions regarding nurse practitioner delivered care. Quite frankly, the arguments are old and tired. My goal as a clinician is to deliver the highest quality, evidence-based, and culturally competent care that I am capable of. I refuse to pit NPs versus other professions. We all have our own slightly varied philosophies and approaches to delivering care. Some may prefer the approach of a DO while some choose to see a NP or PA or MD. I believe patients have that right. However, I cannot believe the nonsense and out of context rubbish posted on the AMA's "Virtual Mentor" in a column entitled, "The Primary Care Shortage, Nurse Practitioners, and the Patient-Centered Medical Home." Oh, where to begin!

The opinion piece begins with the patronizing idea that NPs are part of the solution but not THE solution to the primary care crisis in this country. Funny, but I couldn't find a single reference that states NPs want to solely take over primary care. It goes on to give a functional definition of primary care and states:

Primary care serves four important functions in the delivery of health care: (1) first contact access for each new medical need, (2) long-term, person-focused (not disease-focused) care, (3) comprehensive care for the majority of a person’s health related needs, and (4) coordination of care when it must be sought elsewhere.

Wow, that sounds an awful like what NP philosophy is grounded in:

NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices. They are truly your Partners in Health. In addition to being top-notch healthcare providers, NPs deliver a unique blend of nursing and medical care. They provide comprehensive, personalized health education and counseling. NPs assist patients in making better lifestyle and health decisions.

The next statement in the piece is truly baffling:

Primary care physicians are the only medical professionals who provide patient-centered, integrated, accessible health care that addresses the large majority of patients’ needs in the context of a sustained partnership with the patient and the community [2].

Huh?!? Is that your opinion or is that paraphrased? That reference comes from Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.

I could not find any mention of that within the reference. Unfortunately, there is no page number to cite it from. In fact, reading through this very reference, I found:

...[the] definition of primary care...is presented in terms of the function of primary care, not solely in terms of who provides it" (p. 2).

These authors go on to say that critical elements of primary care include: "services provided by primary care clinicians - generally considered to be physicians, nurse practitioners, physician assistants - but involving a broader array of individuals in a primary care team..." (p.2).

The next few paragraphs suggest that primary care by primary care physicians is *better* than care delivered by anyone else. Of course, these studies aren't even looking at physician-directed care - they just underscore the need for primary care.

Here is another great quote:

Policy discussions about ways to increase the primary care physician workforce have considered utilizing nurse practitioners to address the shortage of primary care physicians. Nurse practitioners are part of the answer, but they are not the solution. Although nurse practitioners provide some types of care that primary care physicians do, their training is very different. There are limits to a nurse practitioner’s ability to deliver the full-service, comprehensive care delivered by primary care physicians.

The limits to a NPs ability to deliver this care has nothing to do with education but oftentimes is restricted by antiquated statutory regulations. Requiring a collaborative agreement costs practices time and money requiring physicians to co-sign charts, which is not a good use of anyone's time, is retrospective, and has no evidence to support enhanced quality in any way.

Next the author mentions the 2004 Cochrane systematic review, "Substitution of doctors by nurses in primary care." A systematic review attempts to use a non-biased systematic approach to review the available evidence from previously completed studies. I am certain that this author did not even read the full review since their criteria was looking for data from the period of 1966-2002 (he sites the lack of "recent" data) and in total only 16 studies were used for inclusion methods (he makes it seem as if the evidence was robust). Incidentally, the review didn't just examine NP care - it also looked at registered nurses trained in primary care and clinical nurse specialists). Incidentally, the reference list in this study has the authors names misspelled. I am also perplexed by this statement:

By comparison, the studies cited above on outcomes in primary care have demonstrated improved patient outcomes with an increased primary care physician workforce [4, 6].

Now maybe its my little NP incapable brain that cannot comprehend all of this data but the aforementioned studies DID NOT EVEN MAKE THIS COMPARISON as he purports! Again, I checked those references and could find no such information.

Next, the author refers to some fuzzy calculations that NPs going into primary care is declining. While this may be true, it is because the NP profession has had explosive growth over the last 10 years and there is no way that it could be sustained. It has also been traditionally difficult to gather accurate data on NPs in the workforce. So, yes, the numbers are declining but not because we are choosing not to go into primary care. In fact, one estimation states there are collectively more NPs and PAs providing primary care than they are family physicians (Green LA, Dodoo MS, Ruddy G, Fryer GE, Phillips RL, McCann JL, et al. The physician workforce of the United States: a family medicine perspective. Washington, D.C.: Robert Graham Center, 2004.)

Finally, the author uses the current buzz-term, the patient-centered medical home, to suggest a physician-centric approach utilizing NPs as "vital team members" will somehow meet the demands of the primary care crisis. This statement is patronizing, is simply misaligned with the definition of primary care and is anything but "patient-centered." If it's truly patient centered, I say let the patient have a say in the provision of care.

To sum, I am woefully disappointed that such a crudely researched article with out of context facts is allowed to be published on a professional organization's website. The Virtual Mentor (VM) "explores the ethical issues and challenges that students, residents, and other physicians are likely to confront in their training and daily practice." This type of rhetoric only begets further silos among disciplines and misrepresents the nurse practitioner profession where ultimately coordination of care and communication is compromised. Shame on them.

I just had to get that off my chest.

Thursday, March 4, 2010

Evidence in Labeling

The NY Times reports that the F.D.A. is cracking down on food manufacturer's health claims on their package labels. I have somewhat mixed feelings on this. On the one hand, if a purported health claim is enough to convince someone to make wiser eating habits, then that has to be a benefit (albeit to the financial advantage of the manufacturer). However, as we strive to incorporate scientific evidence into these health claims, they need to be accurate and actually based on good data. A lot of supplements and vitamins now shy away from clear health claims for fear of the same F.D.A.-type crackdown (though is simply adding the word, "may" to the claim enough? As in "Vitamin C may contribute to increased immunity," etc.)

It seems as if the F.D.A. is willing to work with the manufacturers to convey accurate and scientific information that should satisfy the manufacturers while protecting and correctly informing consumers and this should be lauded.