Ying Xue

The US experienced the fastest growth of its older population from 2010 to 2020 since the decade spanning 1880 to 1890, and this trend is projected to continue.^1,2 In 2020, 16.8% of the US population was 65 years of age or older (55.8 million), and by 2040, it is estimated it will increase to 21.6% (80.8 million).^1,2 As more people live longer, they are disproportionally affected by chronic health conditions.^3,4 The growing number of older adults and the concomitant high prevalence of chronic conditions require an increased supply of specialized geriatric clinicians with advanced training in aging and health.

Nurse practitioners (NPs) constitute the largest and fastest growing group of nonphysician primary care clinicians.¹ As the primary care physician (PCP) shortage persists,¹ examination of trends in primary care NP supply, particularly in relation to populations most in need, will inform strategies to strengthen primary care capacity. However, such evidence is limited, particularly in combination with physician workforce trends. We thus characterized the temporal trends in the distribution of primary care NPs in low-income and rural areas compared with the distribution of PCPs.

Objectives: To document the temporal trends in alternative primary care models in which physicians, nurse practitioners (NPs), or physician assistants (PAs) engaged in care provision to the elderly, and examine the role of these models in serving elders with multiple chronic conditions and those residing in rural and health professional shortage areas (HPSAs). Design: Serial cross-sectional analysis of Medicare claims data for years 2008, 2011, and 2014. Setting: Primary care outpatient setting. Participants: Medicare fee-for-service beneficiaries who had at least 1 primary care office visit in each study year. The sample size is 2 471 498. Measurements: Physician model—Medicare beneficiary’s primary care office visits in a year were conducted exclusively by physicians; shared care model—conducted by a group of professionals that included physicians and either NPs or PAs or both; NP/PA model: conducted either by NPs or PAs or both. Results: There was a decrease in the physician model (85.5% to 70.9%) and an increase in the shared care model (11.9% to 23.3%) and NP/PA model (2.7% to 5.9%) from 2008 to 2014. Compared with the physician model, the adjusted odds ratio (AOR) of receiving NP/PA care was 3.97 (95% CI 3.80-4.14) in rural and 1.26 (95% CI 1.23-1.29) in HPSAs; and the AOR of receiving shared care was 1.66 (95% CI 1.61-1.72) and 1.14 (95% CI 1.13-1.15), respectively. Beneficiaries with 3 or more chronic conditions were most likely to received shared care (AOR = 1.67, 95% CI 1.65-1.70). Conclusion: The increase in shared care practice signifies a shift toward bolstering capacity of the primary care delivery system to serve elderly populations with growing chronic disease burden and to improve access to care in rural and HPSAs.

The evolving role of nurse practitioners (NPs) as primary care providers, especially for vulnerable populations, is central to the debate regarding strategies to address the growing need for primary care services. The current article provides policy recommendations for leveraging and expanding the historic role of NPs in caring for vulnerable populations, by focusing on three key policy levers: NP scope-of-practice regulation, distribution of the NP workforce, and NP education. These policy levers must go hand in hand to build a sufficient and equitably distributed NP workforce, to help meet the escalating need for primary care in an era of health-care reform.

Use of agency-employed supplemental nurses on nursing personnel costs was examined in 19 adult patient care units in a large academic medical center. Results indicated that the modest use of supplemental nurses was cost-efficient with regard to overall nursing personnel costs, but heavy reliance on supplemental nurses to meet staffing needs was not cost-efficient. In addition, there was no statistical difference in hourly personnel cost between the use of supplemental nurses and overtime worked by permanent nurses.

Use of supplemental RNs (SRNs) is common practice among US hospitals to fill gaps in nurse staffing. The objective of this study was to examine the relationship between use of SRNs and patient outcomes. Multilevel modeling was performed to analyze hospital administrative data from 19 hospital units in a large tertiary medical center for the years 2003 to 2006. Patient outcomes included in-hospital mortality, medication errors, falls, pressure ulcers, and patient satisfaction with nurses. Use of SRNs ranged from 0% to 30.4% of total RN hours per unit quarter. Among 188 of the 304 unit quarters in which SRNs were used, the average SRN use was 9.8% in non-ICUs and 6.4% in ICUs. All observed effects of SRN use on patient outcomes were nonsignificant. Use of SRNs was substantial and varied widely by unit. No evidence was found that links SRN use to either adverse or positive patient outcomes.