Nurse practitioners’ workforce outcomes under implementation of full practice authority

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized. (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states? We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions. A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08). As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately. To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Independent practice and full practice authority

This cross-sectional study evaluates whether the Patient Protection and Affordable Care Act (ACA) Shortage Designation Modernization Project is associated with changes in primary care health professional shortage area (PC-HPSA) designations.

BackgroundThe physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.Study designA descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.MethodsThe patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.FindingsIn total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.ConclusionsNPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

Across the United States, nursing practice acts (NPAs) have been revised to include provisions that promote full practice authority (FPA) for nurse practitioners (NPs). Such revisions provide a mechanism to better utilize the full scope of NP services to address growing demands for access to health care. Modernized NPAs that facilitate FPA for NPs are imperative, especially now with the unprecedented health care crisis that the world now faces: Coronavirus Disease 2019. This is the first known study to use an embedded single-case study design, guided by the Kingdon policy stream model, to provide a detailed account of how stakeholders for NP FPA determine the appropriate time to pursue legislative changes to NP scope of practice regulations. Qualitative data analysis revealed four themes which comprised the components considered by stakeholders during their decision-making processes related to NP FPA: participants, problem, policy development, and politics. Themes were further collapsed within concepts from the Kingdon model to form the case description. Study findings can be used to increase the competency among NP FPA stakeholders in determining the timing of legislative pursuits for regulatory change.

The widening gap between urban and rural health outcomes is exacerbated by physician shortages that disproportionately affect rural communities. Rural residencies are an effective mechanism to increase physician placement in rural and medically underserved areas yet are limited in number due to funding. Community health center/academic medicine partnerships (CHAMPs) can serve as a collaborative framework for expansion of academic primary care residencies outside of traditional funding models. This report describes 10-year outcomes of a rural training pathway developed as part of a CHAMP collaboration. Using data from internal registries and public sources, our retrospective study examined demographic and postgraduation practice characteristics for rural pathway graduates. We identified the rates of postgraduation placement in rural (Federal Office of Rural Health Policy grant-eligible) and federally designated Medically Underserved Areas/Populations (MUA/Ps). We assessed current placement for graduates >3 years from program completion. Over a 10-year period, 25 trainees graduated from the two residency expansion sites. Immediately postgraduation, 84% (21) were in primary care Health Professional Shortage Areas (HPSAs), 80% (20) in MUA/Ps, and 60% (15) in rural locations. Sixteen graduates were >3 years from program completion, including 69% (11) in primary care HPSAs, 69% (11) in MUA/Ps, and 50% (5) in rural locations. This CHAMP collaboration supported development of a rural pathway that embedded family medicine residents in community health centers and effectively increased placement in rural and MUA/Ps. This report adds to national research on rural workforce development, highlighting the role of academic-community partnerships in expanding rural residency training outside of traditional funding models.

As recently as November 2024, the National Center for Health Workforce Analysis (NCHWA) of the Health Resources and Services Administration (HRSA) made note of the latest census data of U.S. physicians [1]. It was the conclusion of the NCHWA that the U.S. is presently home to a total of 933,788 "professionally active" physicians of whom 800,355 are "reported as patient care practicing physicians [1]." The NCHWA went on to project a "shortage of 187,130 full-time equivalent (FTE) physicians in 2037" as well as the possibility that "nonmetro areas will experience greater shortages of physicians than metro areas [1]." The NCHWA further estimates that "75 million people live in a primary care Health Professional Shortage Area (HPSA)" and that "a total of 122 million people live in a mental health HPSA [1]." Note was also made of the reality that "the maldistribution of the health care workforce results in severe shortages in rural communities [1]." Seeking to address the extant challenges, a bipartisan group of members of the Senate Committee on Finance stepped into the breach [2]. Led by Sen. Ron L. Wyden (D-OR), it was the intent of the Senators to introduce legislation that will assist teaching hospitals in the training of more physicians by reforming Medicare's Graduate Medical Education (GME) rules [2]. In this Commentary, we review the evolution of the aforementioned draft legislation as well as assess the likelihood of the materialization thereof.

Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states, may be critical to improving outcomes and reducing health care burdens. To evaluate whether nurse practitioner FPA reduces hospital readmissions and emergency department visits related to chronic conditions across the United States. A secondary data analysis using restricted Medical Expenditure Panel Survey (MEPS) data (2010-2019) was performed on site at the Agency of Health Research and Quality. We applied incidence rate ratios (IRRs) and difference-in-difference (DiD) models. Primary outcomes included readmission and emergency visit rates for five chronic conditions: high cholesterol (n=33,409), high blood pressure (n=38,858), diabetes (n=13,075), emphysema (n=2,509), and asthma (n=17,018). Covariates included county-level socioeconomic factors and rurality. States with FPA had modestly lower IRRs for high cholesterol (0.9863), high blood pressure (0.9758), diabetes (0.9746), and asthma (0.9710) compared with restricted states. DiD models showed inconsistent effects, with most FPA*Post coefficients lacking statistical significance. However, rural FPA counties frequently showed significantly lower readmission rates, notably for diabetes and high cholesterol. NP FPA is associated with slight reductions in chronic condition readmissions, particularly in rural areas. While DiD models showed limited policy-specific impact, IRR findings support FPA as a promising strategy to enhance chronic disease management and access to care. Future research should address model limitations and explore causal pathways.

There has long been a shortage of health care providers in rural areas. Interventions that have been shown to increase rural recruitment have yet to be explored in physician associates (PAs). This study seeks to identify the association between PA training site and first job location. We conducted a repeated cross-sectional analysis of recent PA graduates' data at one institution. The institution consists of 2 campuses, an urban and rural campus. We analyzed the data using multivariable logistic regression. We analyzed 7 cohorts (n = 601) of students, of whom 26.29% (n = 158) trained at the rural campus. There were no significant differences between campus locations on any sociodemographic characteristics, except race (White, rural = 78.48% vs. urban = 68.85%, P = .02). Students were more likely to choose a job in a rural area when they completed more rural rotations (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.22-1.70), controlling for primary care specialty, gender identity, attending a rural campus, and being raised in an economically disadvantaged area. In a sensitivity analysis of more recent cohorts, we found similar results. Training at a rural campus or completing rural rotations were not associated with obtaining jobs in primary care health professional shortage areas or medically underserved areas. Similar to research in medical students, PAs who complete clinical training in rural areas may be more likely to choose their first job in a rural area, independent of where they were raised. This has policy and institutional implications to address access to care disparities for rural populations.

This policy analysis examines the limited practice authority for advanced practice registered nurses (APRN) in the Southeastern United States, focusing on Tennessee while drawing comparisons to Georgia and Alabama. The PICO question that guided this policy analysis is: For advanced practice registered nurses within the southeast region of the United States (P), how does the development of a comprehensive policy recommendation for full practice authority (I), compared to existing reduced or restricted practice authority in the southeast region of the United States (C) affect access to care as endorsed by literature (O)? The literature suggests that despite being equipped with the education, accreditation, certification, and licensure, APRNs in the Southeastern states still have regulatory and nonregulatory barriers to practice, impeding their ability to provide access to care, especially in rural and underserved communities. Moreover, the literature strongly advocates adopting evidence-based recommendations by the American Association of Nurse Practitioners, the Consensus Model, and The Academy of Medicine to modernize the outdated regulatory and nonregulatory barriers impeding APRNs. A policy brief is also proposed to engage stakeholders in advocating for these evidence-based recommendations and securing APRNs' full practice authority. Eliminating these barriers allows APRNs to work to their full ability, resulting in enhanced healthcare access, improved quality, reduced healthcare disparities, and potentially lowered healthcare costs.

Physician shortages lead to longer wait times, shorter patient visits, and lower-quality patient interactions, resulting in a greater risk for misdiagnosis and an overall decrease in the quality of care they provide. In this viewpoint, we reviewed the issues surrounding full practice authority (FPA) for nurse practitioners (NPs) in the United States (US). We summarized evidence regarding the safety, quality, and efficacy of NPs in states that have enacted FPA and describes the role of NPs in closing the gap of unmet healthcare needs of the US population. We also described the success of states with FPA in their legislative efforts while other states are still plagued by barriers to FPA, providing context on the political environment surrounding FPA bills. The analysis of FPA for NPs meeting the healthcare needs of the US population can further inform policy to aid in similar healthcare needs globally.

Nurse Practitioners in Emergency Care

There is a need to understand population race and ethnicity disparities in the context of sociodemographic risk factors in the US experience of the COVID-19 pandemic. Determine the association between county-level proportion of non-Hispanic Black (NHB) on county COVID-19 case and death rates and observe how this association was influenced by county sociodemographic and health care infrastructure characteristics. This was an ecologic analysis of US counties as of September 20, 2020, that employed stepwise construction of linear and negative binomial regression models. The primary independent variable was the proportion of NHB population in the county. Covariates included county demographic composition, proportion uninsured, proportion living in crowded households, proportion living in poverty, population density, state testing rate, Primary Care Health Professional Shortage Area status, and hospital beds per 1000 population. Outcomes were exponentiated COVID-19 cases per 100 000 population and COVID-19 deaths per 100 000 population. We produced county-level maps of the measures of interest. In total, 3044 of 3142 US counties were included. Bivariate relationships between the proportion of NHB in a county and county COVID-19 case (Exp β = 1.026; 95% confidence interval [CI], 1.024-1.028; P < .001) and death rates (rate ratio [RR] = 1.032; 95% CI, 1.029-1.035; P < .001) were not attenuated in fully adjusted models. The adjusted association between the proportion of NHB population in a county and county COVID-19 case was Exp β = 1.025 (95% CI, 1.023-1.027; P < .001) and the association with county death rates was RR = 1.034 (95% CI, 1.031-1.038; P < .001). The proportion of NHB people in a county was positively associated with county COVID-19 case and death rates and did not change in models that accounted for other socioecologic and health care infrastructure characteristics that have been hypothesized to account for the disproportionate impact of COVID-19 on racial and ethnic minority populations. Results can inform efforts to mitigate the impact of structural racism of COVID-19.

Assessing the Geographic Distribution of Community-Based Pharmacy Residency Programs in Areas of Health Care Need.

Progress Is Its Own Success, but It Is Not the Goal