Association of number of primary care physicians with preventable hospitalizations and premature deaths

Background Team care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care. This study aimed to compare the processes and outcomes of care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs). Methods We studied 3,524 primary care practices identified via social network analysis and 306,741 patients ≥66 years old diagnosed with diabetes in or before 2015 in Medicare data. Guideline-recommended diabetes care included eye examination, hemoglobin A1c test, and nephropathy monitoring. High-risk medications were based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Preventable hospitalizations were defined as hospitalizations for a potentially preventable condition. Results Compared with patients in the PCP only teams, patients in the team care practices with NPs or PAs received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio (aOR): 1.04 (95% CI: 1.00–1.08), 1.08 (95% CI: 1.03–1.13), and 1.10 (95% CI: 1.05–1.15), and HbA1C test: aOR: 1.11 (95% CI: 1.04–1.18), 1.11 (95% CI: 1.02–1.20), and 1.15 (95% CI: 1.06–1.25) for PCP/NP, PCP/NP/PA, and PCP/PA teams). Patients in the PCP/NP and the PCP/PA teams had a slightly higher likelihood of being prescribed high-risk medications (aOR: 1.03 (95% CI: 1.00–1.07), and 1.06 (95% CI: 1.02–1.11), respectively). The likelihood of preventable hospitalizations was similar among patients cared for by various types of practices. Conclusion The team care practices with NPs or PAs were associated with better adherence to clinical practice guideline recommendations for diabetes compared to PCP only practices. Both practices had similar outcomes. Further efforts are needed to explore new and cost-effective team-based care delivery models that improve process, outcomes, and continuity of care, as well as patient care experiences.

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Fool’s Gold: Psychologists Using Disingenuous Reasoning to Mislead Legislatures into Granting Psychologists Prescriptive Authority

American Journal of Law & Medicine ◽

10.1017/s0098858800002586 ◽

2003 ◽

Vol 29 (4) ◽

pp. 489-524

Author(s):

Brent Pollitt

Keyword(s):

Primary Care ◽

Mental Illness ◽

Nurse Practitioners ◽

Primary Care Physicians ◽

American Psychological Association ◽

The United States ◽

Psychotropic Medications ◽

American Psychological ◽

Training Requirements ◽

Prescriptive Authority

Mental illness is a serious problem in the United States. Based on “current epidemiological estimates, at least one in five people has a diagnosable mental disorder during the course of a year.” Fortunately, many of these disorders respond positively to psychotropic medications. While psychiatrists write some of the prescriptions for psychotropic medications, primary care physicians write more of them. State legislatures, seeking to expand patient access to pharmacological treatment, granted physician assistants and nurse practitioners prescriptive authority for psychotropic medications. Over the past decade other groups have gained some form of prescriptive authority. Currently, psychologists comprise the primary group seeking prescriptive authority for psychotropic medications.The American Society for the Advancement of Pharmacotherapy (“ASAP”), a division of the American Psychological Association (“APA”), spearheads the drive for psychologists to gain prescriptive authority. The American Psychological Association offers five main reasons why legislatures should grant psychologists this privilege: 1) psychologists’ education and clinical training better qualify them to diagnose and treat mental illness in comparison with primary care physicians; 2) the Department of Defense Psychopharmacology Demonstration Project (“PDP”) demonstrated non-physician psychologists can prescribe psychotropic medications safely; 3) the recommended post-doctoral training requirements adequately prepare psychologists to prescribe safely psychotropic medications; 4) this privilege will increase availability of mental healthcare services, especially in rural areas; and 5) this privilege will result in an overall reduction in medical expenses, because patients will visit only one healthcare provider instead of two–one for psychotherapy and one for medication.

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