Search

To understand patients' and providers' perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System.Qualitative exploratory study (in convergent mixed-methods design).Semi-structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis.We interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers' professional experience outweighed provider type.Patients' preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers' perceptions suggest NPs and physicians are both viable providers for primary care.Nurse Practitioners (NPs): practice authority Veterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care delivery United States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much-needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiences.目标: 了解患者和医疗机构对退伍军人医疗保健系统中护理师提供初级护理的看法。 设计: 探索性的定性研究(收敛混合方法设计)。 方法: 2016年进行的半结构化访谈,采访了州内拥有护理师的全科和非全科执业机构的初级护理提供者和患者。重新分配患者样本:(a) 一名护理师;或(b)确立医生关系的另一名医生。采用内容分析法对数据进行分析。 结果: 我们采访了28名患者,17名医生和14名护理师。我们发现:(a)护理师比医生提供的护理更全面;(b)患者对护理师感到满意;(c)医疗机构的专业经验的权重比医疗机构类型的权重更大。 结论: 患者对护理师的偏好(与以前的医生相比)有助于建立以患者为中心的认知。提供者的观念类似,表明护理师和医生都是可行的初级护理提供者。 影响: •护理师:执业机构 •退伍军人医疗保健系统:护理师将继续作为提供初级护理服务的可用资源。 •美国卫生保健:挑战观念 患者可能不满意由护理师提供的护理,其会支持扩大使用范围,以提供急需的初级保健服务;扩大全科执业机构将使各州能够提供可接受的初级保健服务,而不会减弱患者或提供者的体验。.

Objective To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients. Data sources Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. Study design We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. Principal findings Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. Conclusions Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.

BACKGROUND: The Veterans Choice Program (VCP) was implemented to improve healthcare access by expanding healthcare options for Veterans Health Administration (VHA) enrollees. OBJECTIVES: To understand Veterans’ experience accessing VCP care. DESIGN: Qualitative content analysis. SUBJECTS: Forty-seven veterans from three medical centers in three of the five VA geographical regions. APPROACH: We used semi-structured telephone interviews designed to elicit descriptions of Veterans’ experiences. Data was analyzed using iterative, inductive, and deductive content analysis. Broad themes were identified based on representative interview responses. KEY RESULTS: We identified six themes: general impressions (concept and frustration); preferred source of care (institution, specialty, and individual provider); facilitators (VA staff facilitation and proactive Veterans); barriers (complexity, lack of responsiveness, lack of local providers, and poor coordination); perceived sources of VCP problems (learning curve, leadership and staff, and politics); and unintended negative impact (responsibility for costs of care and discontinued access to community care). DISCUSSION: Most Veterans who had received care through the VCP felt that it improved their access to care. However, accessing care through the VCP is a complex process that requires proactive Veterans and active support from the VA, third-party administrators, and availability of participating community providers. Veterans’ abilities to navigate this process and the level of support provided varied widely. Even patients who did receive care through VCP found the process challenging. Greater support is needed for some Veterans to successfully access VCP care because Veterans who need care the most may be the least able to access it.

BACKGROUND Discharge rates are substantially lower on weekends, though the impact on hospital length of stay (LOS) is not fully understood. OBJECTIVES The primary objective was to examine the association of weekend discharges with hospital LOS. We also examined the association of weekend discharges with readmission, mortality, and postdischarge follow-up. RESEARCH DESIGN AND METHODS A cohort study of 25,301 patients who were admitted to Veterans Affairs hospitals for chronic obstructive pulmonary disease during October 01, 2008-September 30, 2010, including 3845 patients discharged on the weekend (Saturday or Sunday) and 21,456 discharged on weekdays (Monday through Friday). RESULTS There were significantly fewer discharges on the weekend (1922 per weekend day vs. 4279 per weekday, P

Background and objectives The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)—the largest non–fee-for-service health system in the United States. Design, setting, participants, & measurements The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 ( n =971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: ( 1 ) veterans whose dialysis was paid for by the VA, ( 2 ) veterans whose dialysis was not paid for by the VA, and ( 3 ) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m 2 . Results The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m 2 increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients ( P for interaction P for interaction Conclusions Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.

Objective To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals. Data Sources Simulated data. Study Design Through simulations, we compared the “minority-serving” approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a “fixed-effect” approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a “between-hospital” disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality. Principal Findings The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35–46 percent. Conclusions Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.

Background/Objective: Though the safety of transradial percutaneous coronary intervention (TRI) has been demonstrated in clinical trial and registry studies, adoption of TRI in the United States has been slow. We fielded a national survey with VA interventional cardiologists to understand factors influencing TRI use. Methods: The structured survey was developed from telephone interviews with interventional cardiologists, catheterization laboratory nurses and radiology technicians at 3 VA hospital cath labs. The survey assessed extent of interventional cardiologists’ experience with TRI, perceptions of the advantages or disadvantages of TRI relative to transfemoral PCI (TFI), and barriers to adopting and implementing TRI. We used the the Cardiovascular Assessment Reporting and Tracking (CART) registry to define our sampling frame, all VA interventional cardiologists, and to obtain cath lab TRI rates. We tested whether respondents’ opinions of the relative advantages of and barriers to TRI were associated with site-level TRI rates in a 13-month period following to the survey (January 2012 to January 2013). Results: We received responses from 78 of 235 interventional cardiologists representing 48 of 65 VA cath labs (33% response rate; 73% of cath labs). The most prevalent barriers to TRI adoption cited by cardiologists were increased radiation exposure to the cardiologist (63% cited as a major or minor barrier) or staff (51% of respondents), and the steep learning curve (44%). Other barriers such as difficulty obtaining necessary equipment (25%), lack of support from cath lab staff (23%), and lack of training opportunities (18%), were less prevalent. The majority of cardiologists rated TRI as superior for ease of post-procedure monitoring (52%), patient comfort (60%), early discharge (65%), fewer vascular access complications (69%), and less bleeding (72%). However, a majority rated TFI superior for shorter procedure duration (69%) and technical results (47% rated superior, 49% as no difference). One-year cath lab TRI rates ranged from 1.1% (3 of 270) to 90.2% (286 of 317), with a median of 7.3%. Only nine cath labs had a 1-year TRI rate greater than 50%. No barriers were correlated with TRI rates; however, all of the relative advantage measures were significantly, positively correlated. The strongest correlations were for faster procedure time (r=.59, p Conclusions: This study demonstrates that while interventional cardiologists are familiar with the advantages of TRI over TFI, there is still limited adoption of TRI on a broad scale. There were no reported barriers associated with site-level radial rates suggesting that obstacles to TRI adoption are likely multifactorial. Effective TRI training programs should focus on methods to reduce radiation exposure and manage expectations about the radial learning curve.