Impact of State Nurse Practitioner Regulations on Potentially Inappropriate Medication Prescribing Between Physicians and Nurse Practitioners: A National Study in the United States.
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ABSTRACT: Background
The American Geriatrics Society regularly updates the Beers Criteria for Potentially Inappropriate Medication (PIM) to improve prescribing safety.Purpose
This study assessed the impact of nurse practitioner (NP) practices on PIM prescribing across states in the United States and compared the change in PIM prescribing rates between 2016 and 2018.Methods
We used data from a random selection of 20% of Medicare beneficiaries (66 years or older) from 2015 to 2018 to perform multilevel logistic regression. A PIM prescription was classified as initial or refill on the basis of medication history 1 year before a visit. PIM use after an outpatient visit was the primary study outcome.Results
We included 9 000 224 visits in 2016 and 9 310 261 in 2018. The PIM prescription rate was lower in states with full NP practice and lower among NPs than among physicians; these rates for both physicians and NPs decreased from 2016 to 2018.Conclusions
Changes could be due to individual state practices.
SUBMITTER: Tzeng HM
PROVIDER: S-EPMC8608008 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundPotentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.ObjectiveWe aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.Research designWe used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.ResultsThere were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.ConclusionsNPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.
| S-EPMC8273104 | biostudies-literature
Project description:Background Portugal has among the highest rates of dependency among older adults in Europe. Older adults with aging-related comorbidities are prone to the use of potentially inappropriate medication (PIM). Objective The aim of this study was to analyze PIM prescriptions in older Portuguese adults, as well as the change rate of PIM prescriptions over time, and assess the geographical variability between the different regions of mainland Portugal. Methods Using a national database, PIM prescriptions were analyzed for older adults (aged 65 years and older) between 2019 and 2021 from 2 perspectives: PIM-defined daily dose (DDD) frequency (%) and DDD per 1000 inhabitants per day (DID). Results Overall, mainland Portugal presented a PIM DDD frequency of 9.20%, which was relatively higher in Alentejo and Centro and lower in the North. Alprazolam, fluoxetine, and rivaroxaban were PIM with higher DDD frequency values. Over the years, the DID change rates for these three PIM were –3.80%, –14.86%, and +18.54%, respectively, depending on the geographic region. Alprazolam and fluoxetine were mostly prescribed to older women, whereas rivaroxaban was mostly prescribed to older men. Conclusions These results emphasize the need to implement initiatives and interventions to decrease PIM prescriptions in older adults.
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Project description:ObjectiveTo measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients.DesignWe studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management.SettingPatients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont.ParticipantsA total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes.InterventionA pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later.Main outcome measuresWe used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial.ResultsAt baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50).ConclusionWe observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses.Trial registration numberNCT00238836 (ClinicalTrials.gov).
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Project description:ObjectiveTo determine if there are differences in opioid prescribing among generalist physicians, nurse practitioners (NPs), and physician assistants (PAs) to Medicare Part D beneficiaries.DesignSerial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services.SubjectsAll generalist physicians, NPs, and PAs who provided more than 10 total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.MethodsThe main outcomes were total opioid claims and opioid claims as a proportion of all claims in patients treated by these prescribers in each of the three settings of interest. Binomial regression was used to generate marginal estimates to allow comparison of the volume of claims by these prescribers with adjustment for practice setting, gender, years of practice, median income of the ZIP code, state fixed effects, and relevant interaction terms.ResultsThere were 36,999 generalist clinicians (physicians, NPs, and PAs) with at least one year of Part D prescription drug claims data between 2013 and 2016. The number of adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval [CI] = 660-661), for NPs was 755 (95% CI = 753-757), and for PAs was 812 (95% CI = 811-814).ConclusionsWe find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.
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Project description:(1) Background: Some medications may be dangerous for older patients. Potentially inappropriate medication prescribing (PIP) among older patients represents a significant cause of morbidity. The aim of this study was to create an algorithm to detect PIP in a geriatric database (Multidomain Alzheimer Preventive Trial (MAPT) study), and then to assess the algorithm construct validity by comparing the prevalence of PIP and associated factors with literature data. (2) Methods: An algorithm was constructed to detect PIP and was based on different explicit criteria among which the European list of potentially inappropriate medications (EU(7)-PIM), the STOPP and START version 2 tools. For construct validity assessment, logistic mixed-effects model repeated measures analyses were used to identify factors associated with PIP. (3) Results: Prevalence of PIP was 59.0% with the EU(7)-PIM list criteria, 43.2% with the STOPP criteria and 51.3% with the START criteria. Age, polypharmacy, and higher Charlson comorbidity index were associated with PIP. (4) Conclusions: Prevalence of PIP and associated factors are consistent with literature data, supporting the construct validity of our algorithm. This algorithm opens up interesting perspectives both in terms of analysis of very large databases and integration into e-prescribing or pharmaceutical validation software.
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Project description:OBJECTIVES:To estimate the prevalence and determinants of the use of potentially inappropriate medications (PIMs) in older U.S. adults using the 2012 Beers criteria. DESIGN:Retrospective cohort study in a random national sample of Medicare beneficiaries. SETTING:Fee-for-service Medicare beneficiaries from 2007 to 2012. PARTICIPANTS:U.S. population aged 65 and older with Parts A, B, and D enrollment in at least 1 month during a calendar year (N = 38,250 individuals; 1,308,116 observations). MEASUREMENTS:The 2012 Beers criteria were used to estimate the prevalence of the use of PIMs in each calendar month and over a 12-month period using data on diagnoses or conditions present in the previous 12 months. Generalized estimating equations were used to account for the dependence of multiple monthly observations of a single person when estimating 95% confidence intervals (CIs), and logistic regression was used to identify independent determinants of PIM use. RESULTS:The point prevalence of the use of PIMs decreased from 37.6% (95% CI = 37.0-38.1) in 2007 to 34.2% (95% CI = 33.6-34.7) in 2012, with a statistically significant 2% (95% CI = 1-3%) decline per year assuming a linear trend. The 1-year period prevalence declined from 64.9% in 2007 to 56.6% in 2012. The strongest predictor of PIM use was the number of drugs dispensed. Individuals aged 70 and older and those seen by a geriatrician were less likely to receive a PIM. CONCLUSION:From 2007 to 2012, the prevalence of PIM use in older U.S. adults decreased according to the 2012 Beers criteria, although it remains high, still affecting one-third each month and more than half over 12 months. The number of dispensed prescriptions could be used to target future interventions.
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Project description:BackgroundInappropriate use of antibiotics promotes antibiotic resistance. Little is known about physician characteristics that may be associated with inappropriate antibiotic prescribing. Our objective was to assess whether physician knowledge, time in practice, place of training and practice volume explain the differences in antibiotic prescribing among physicians.MethodsA historical cohort of 852 primary care physicians in Quebec who became certified between 1990 and 1993 was followed for their first 6-9 years of practice (1990-1998). We evaluated whether inappropriate antibiotic prescribing had occurred during the study period (1990-1998) for viral (prescription of antibiotics) and bacterial (prescription of second-or third-line antibiotics given orally) infections. We used logistic regression to estimate the independent contributions of time in practice, practice volume, place of medical training and scores on licensure examinations. Physician sex and visit setting were controlled for, as were patient age, sex, education, income and geographic area of residence.ResultsA total of 104 230 patients who received a diagnosis of a viral infection and 65 304 who received a diagnosis of a bacterial infection were included in our study. International medical graduates were more likely than University of Montréal graduates to prescribe antibiotics for viral respiratory infections (risk ratio [RR] 1.78, 95% confidence interval [CI] 1.30-2.44). Inappropriate antibiotic prescribing increased with time in practice. Physicians with a high practice volume were more likely than those with low practice volume to prescribe antibiotics for viral respiratory infections (RR 1.27, 95% CI 1.09-1.48) and to prescribe second-and third-line antibiotics as first-line treatment (RR 1.20, 95% CI 1.06-1.37). Physician scores on licensure examinations were not predictive of inappropriate antibiotic prescribing.InterpretationInternational medical graduates, physicians with high-volume practices and those who were in practice longer were more likely to prescribe antibiotics inappropriately. Developing effective interventions will require increased knowledge of the mechanisms that underlie these predictors of inappropriate antibiotic prescribing.
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Project description:BackgroundThe estimated increase in Alzheimer's Disease (AD) caseload may present a logistical challenge to the US healthcare system. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly delivering primary care to patients with chronic diseases, the nature of their prescribing of AD medications is largely unknown. The primary objective of this study was to compare the prescribing of AD medications across provider types (physician, NP, and PA) and geographic regions.MethodsWe conducted a retrospective cohort study using IBM MarketScan® commercial and Medicare supplemental claims to examine unique AD prescriptions prescribed between January 1, 2016, and December 31, 2019. Parallel analysis of prescriptions for another geriatric condition, osteoporosis (OP), was also conducted for comparison.ResultsA total of 103,067 AD prescriptions and 131,773 OP prescriptions were included in analyses. Physicians prescribed most AD prescriptions (95.65%), followed by NPs (3.37%) and PAs (0.98%). Small differences were identified among individual AD medications prescribed by physicians compared to NP/PAs. NPs/PAs prescribed a significantly higher proportion of AD prescriptions in rural as compared to urban areas (z = 0.023, 95%CI [0.018, 0.028]).ConclusionMinimal variation exists in AD prescribing among physicians, NPs, and PAs, but NPs/PAs prescribe more AD prescriptions in rural areas. NPs/PAs, especially in rural areas, may play critical roles in alleviating projected workforce constraints. Further research assessing AD care, health outcomes, and costs by provider type and region is necessary to better guide healthcare workforce planning for AD care.
| S-EPMC9233396 | biostudies-literature
Project description:Few comparisons exist of the quality of primary care provided by nurse practitioners (NPs) versus physicians.Patients with a diagnosis of diabetes in 2007-2010 (n=345,819) who received all primary care from NPs or from generalist physicians in a given year were selected from a national sample of Medicare beneficiaries. We compared the rate of potentially preventable hospitalizations among patients who received primary care from NPs versus generalist physicians. Various statistical methods-including multivariable analysis, inverse probability weighting of propensity score, nonpooling propensity score adjustment and matching, and instrumental variable (IV) analysis-were used to control for differences in patient characteristics between the 2 groups.Patients who received all of their primary care from NPs or from physicians differed by age, sex, race/ethnicity, socioeconomic status, residential area, and number of provider visits in the previous year. Nonpooling propensity score matching substantially reduced the differences, but neither IV approach satisfactorily reduced the differences. In multivariable analyses, receipt of primary care from an NP was associated with a decreased risk of hospitalization for potentially preventable conditions (OR: 0.90; 95% CI, 0.87-0.93). Similar results were found using conditional logistic regression models with propensity methods. We found smaller reductions in our analyses of "other hospitalizations" (OR: 0.96; 95% CI, 0.95-0.98). Both IV analyses showed associations between NP care and lower potentially preventable hospitalizations, but only 1 result was statistically significant.Using potentially preventable hospitalizations as a quality indicator, primary care provided by NPs was at least comparable with that provided by generalist physicians.
| S-EPMC4536572 | biostudies-other
Project description:ImportanceTime is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.ObjectiveTo investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.Design, setting, and participantsThis cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023.Main outcomes and measuresRegression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics.ResultsThis study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points).Conclusions and relevanceIn this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.
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