Optimizing the Value of Primary Care Delivered by Nurse Practitioners

Va Puget Sound Healthcare System, Seattle WA

Investigators

Linked publications, trials & patents

Abstract

DESCRIPTION (provided by applicant): Background: VA is at the leading edge of employing NPs to deliver primary care and is the largest employer of NPs in the US. NPs accounted for 20% of the VA primary care provider workforce and provided more than 2 million primary care visits a year. Research supports that primary care NPs provide safe, effective care comparable to MDs in general populations, while VA patients are more clinically complex requiring more intensive clinical management. NPs play a crucial role in the VA's Patient Aligned Care Team (PACT) initiative to transform primary care into team care to be more patient centered. At the same time, the VA is under pressure to provide high value care, i.e., to achieve the goals of PACT at the lowest cost. One approach may be the structured assignment of patients defined as assigning patients to NPs based on health risk to ensure NPs operate at the top of their scopes of practice. Objectives: The specific aims of the study are: 1) examine healthcare utilization and costs between patients cared for by NPs and MDs across a range of health risk based on the Care Assessment Need (CAN), which is currently deployed in primary care; 2) compare patient clinical outcomes and patient satisfaction between patients cared for by NPs and MDs across a range of health risk based on the CAN Score; and 3) assess patient experience and feasibility of the structured patient assignment using qualitative interviews. Research Design/Methods: This study uses a multi-methods approach. For the quantitative aims (Aims 1 and 2), we will use a retrospective cohort study using an instrumental variable approach to assess the outcomes of the structured patient assignment to NPs. We will use existing administrative data and VA Survey of Healthcare Experience of Patients. To minimize the patient selection bias, we will include patients who were administratively reassigned from an MD PCP to a new MD or NP because the original MD left the VA primary care from FY2010 to FY2013 in the VA. The outcomes include healthcare utilization and costs for outpatient visits and inpatient admissions; clinical outcomes for patient panel management (lipid control for ischemic heart disease, glycemic control for diabetes, and blood pressure control for hypertension); and patient satisfaction. We will use the restriction in NP independent practice at the state level as instruments, because they are associated with the probability of being assigned to an NP, but not associated with patient outcomes. For the qualitative aim (Aim 3), we will assess patient experience with their new PCPs using patient interviews and assess acceptability and feasibility of the structured patient assignment using interviews of primary care clinicians and clinic managers.