Diabetes Care Processes and Outcomes in Patients Treated by Nurse Practitioners or Physicians

Lenz, Elizabeth R.; Mundinger, Mary OʼNeil; Hopkins, Sarah C.; Lin, Susan; Smolowitz, Janice

doi:10.1177/014572170202800413

Cited by 66 publications

(44 citation statements)

References 20 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Nurse practitioners have been reported to be more likely to follow guidelines and document care [37, 38]. In addition, NPs may be more likely to accept CDSS recommendations about drugs as a result of having less pharmacology training than physicians [39].…”

Section: Discussionmentioning

confidence: 99%

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

Ancker

Edwards

Nosal

et al. 2017

BMC Med Inform Decis Mak

383

291

View full text Add to dashboard Cite

BackgroundAlthough alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. We tested hypotheses arising from two possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time.MethodsRetrospective cohort study using electronic health record data (both drug alerts and clinical practice reminders) from January 2010 through June 2013 from 112 ambulatory primary care clinicians. The cognitive overload hypotheses were that alert acceptance would be lower with higher workload (number of encounters, number of patients), higher work complexity (patient comorbidity, alerts per encounter), and more alerts low in informational value (repeated alerts for the same patient in the same year). The desensitization hypothesis was that, for newly deployed alerts, acceptance rates would decline after an initial peak.ResultsOn average, one-quarter of drug alerts received by a primary care clinician, and one-third of clinical reminders, were repeats for the same patient within the same year. Alert acceptance was associated with work complexity and repeated alerts, but not with the amount of work. Likelihood of reminder acceptance dropped by 30% for each additional reminder received per encounter, and by 10% for each five percentage point increase in proportion of repeated reminders. The newly deployed reminders did not show a pattern of declining response rates over time, which would have been consistent with desensitization. Interestingly, nurse practitioners were 4 times as likely to accept drug alerts as physicians.ConclusionsClinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert. Reducing within-patient repeats may be a promising target for reducing alert overrides and alert fatigue.

show abstract

Section: Discussionmentioning

confidence: 99%

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

Ancker

Edwards

Nosal

et al. 2017

BMC Med Inform Decis Mak

383

291

View full text Add to dashboard Cite

show abstract

“…Higher one-year cost for personnel. Lenz et al (2002) Diabetes care processes and outcomes in patients treated by NPs or physicians NPs more likely to give education about nutrition, weight, exercise and medications. NPs prescribed monitoring tests more frequently than GPs.…”

Section: Authormentioning

confidence: 99%

Nurses in Advanced Roles

Delamaire¹,

Lafortune

2010

OECD Health Working Papers

124

View full text Add to dashboard Cite

All Health Working Papers are now available through the OECD's Internet Website at http:/www.oecd.org/els/health/workingpapers This series is designed to make available to a wider readership health studies prepared for use within the OECD. Authorship is usually collective, but principal writers are named. The papers are generally available only in their original language -English or French -with a summary in the other.Comment on the series is welcome, and should be sent to the Directorate for Employment, Labour and Social Affairs, 2, rue André-Pascal, 75775 PARIS CEDEX 16, France.The opinions expressed and arguments employed here are the responsibility of the author(s) and do not necessarily reflect those of the OECD. ABSTRACTMany countries are seeking to improve health care delivery by reviewing the roles of health professionals, including nurses. Developing new and more advanced roles for nurses could improve access to care in the face of a limited or diminishing supply of doctors. It might also contain costs by delegating tasks away from more expensive doctors. This paper reviews the development of advanced practice nurses in 12 countries (Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, United Kingdom and United States), with a particular focus on their roles in primary care. It also reviews the evaluations of impacts on patient care and cost.The development of new nursing roles varies greatly. The United States and Canada established "nurse practitioners" in the mid-1960s. The United Kingdom and Finland also have a long experience in using different forms of collaboration between doctors and nurses. Although development in Australia and Ireland is more recent, these two countries have been very active in establishing higher education programmes and posts for advanced practice nurses in recent years. In other countries, the formal recognition of advanced practice nurses is still in its infancy, although unofficial advanced practices may already exist in reality.Evaluations show that using advanced practice nurses can improve access to services and reduce waiting times. Advanced practice nurses are able to deliver the same quality of care as doctors for a range of patients, including those with minor illnesses and those requiring routine follow-up. Most evaluations find a high patient satisfaction rate, mainly because nurses tend to spend more time with patients, and provide information and counselling. Some evaluations have tried to estimate the impact of advanced practice nursing on cost. When new roles involve substitution of tasks, the impact is either cost reducing or cost neutral. The savings on nurses' salaries -as opposed to doctors -can be offset by longer consultation times, higher patient referrals, and sometimes the ordering of more tests. When new roles involve supplementary tasks, some studies report that the impact is cost increasing.Keywords: nurses, advanced roles, skills, nurse practitioners, clinical nurse specialists, primary care, OECD countrie...

show abstract

“…Previous studies, including randomized trials, that have matched patients to specifi c midlevel and physician clinicians have found similar results for NPs, however. 19,22 A strength of this study is that it examines the overall effect of teams of clinicians in family medicine practices on treating patients with diabetes. This approach is consistent with several major recommendations arguing that primary care practices should use teams of clinicians working together to treat populations of patients.…”

Section: Discussionmentioning

confidence: 99%

“…13,14 Most randomized clinical trials and observational studies have focused on comparing the quality of care between physicians and NPs, with relatively little published research comparing PAs with either physicians or NPs. 9,[15][16][17][18] For example, in a study comparing NP and physician performance in the care and attainment of outcomes for patients with diabetes, Lenz et al 19 found signifi cant differences in documentation but not in patient outcomes. Some have argued that NPs may enhance primary care because they are trained specifi cally for health promotion and education.…”

Section: Introductionmentioning

confidence: 99%

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

Ohman‐Strickland¹,

Orzano²,

Hudson³

et al. 2008

The Annals of Family Medicine

103

View full text Add to dashboard Cite

PURPOSE 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.METHODS 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 identifi ed by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTSCompared 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 ≤.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 ≤.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.CONCLUSIONS 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. Ann Fam Med 2008;6:14-22. DOI: 10.1370/afm.758. INTRODUCTIONI ncreasingly, nurse-practitioners (NPs) and physician's assistants (PAs) serve as a primary point of contact for patients within primary care practices.1,2 Bolstering this trend is the development of new models of primary care practice advocating collaborative teams of diverse clinicians.3-5 Yet, among family physicians, some uncertainty and unease persists about the use of these clinicians, [6][7][8] particularly with regard to quality of care, 9,10 patient satisfaction, 11,12 and fi nancial effi ciency. 13,14 Most randomized clinical trials and observational studies have focused on comparing the quality of care between physicians and NPs, with relatively little published research comparing PAs with either physicians or NPs. 9,[15][16][17][18] For example, in a study comparing NP and physician performance in the care and attainment of outcomes for patients with diabetes, Lenz et al 19 found signifi cant differences in documentation but not in patient outcomes. Some have argued that NPs may enhance primary care because they are trained specifi cally for health promotion and education. 2,20,21 In fact, Hopkins et al 22 found that compared with physicians, NPs performed better at secondary prevention, assessment, and counseling. QU A L I T Y O F DIA BE T ES C A R E W I T H NP s A ND PA sSakr et al 16 found that patients cared for by NPs received more inf...

show abstract

Diabetes Care Processes and Outcomes in Patients Treated by Nurse Practitioners or Physicians

Cited by 66 publications

References 20 publications

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

Nurses in Advanced Roles

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

Contact Info

Product

Resources

About