What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study.

Independent practice and full practice authority

Nurse practitioners’ workforce outcomes under implementation of full practice authority

To evaluate the association between Texas Affordable Care Act rating area change and health plan enrollment, plan selection, and premiums from 2022 to 2024 for urban and rural counties. Texas integrated a rating area consisting of all 177 rural counties into nearby metropolitan rating areas in 2023. We analyzed this policy using enrollment data from the Marketplace Open Enrollment County-Level Public Use Files from 2022-2024. We calculated the growth in enrollment across rural and urban counties and estimated linear regression models to understand whether enrollment grew faster in rural counties than in urban counties after the policy change. Total marketplace plan enrollment increased by 80% (95% CI, 70%-90%) in urban counties and 76% (95% CI, 68%-84%) in rural counties. Urban and rural counties experienced the largest growth among enrollees aged 35 to 44 years (urban: 107%; 95% CI, 94%-119%; rural: 103%; 95% CI, 95%-112%) and enrollees with incomes between 100% and 150% of the federal poverty level (urban: 124%; 95% CI, 106%-142%; rural: 116%; 95% CI, 106%-127%). The share of counties reporting gold plan enrollment increased in urban and rural counties from 70% to 95% and 51% to 93%, respectively. Rating area changes were not associated with differential enrollment changes across rural and urbancounties. We found similar growth rates in enrollment for rural and urban counties. Marketplace enrollees were more likely to choose a gold plan, suggesting that they shifted away from less-expensive bronze plans.

Food insecurity is influenced by multiple determinants including socioeconomic status, and the Supplemental Nutrition Assistance Program (SNAP) was established to bridge the nutritional gap between low- and high-income households. Food insecurity continues to be a growing disparity among rural and urban communities in the country. Few studies analyze both rural and urban food insecurity, and none do so at the state or county levels. Therefore, we sought to understand the impact of socioeconomic factors on food insecurity in urban and rural households at the state and county levels. We examined urban and rural counties in Pennsylvania (PA), a state with moderate food insecurity rates that are consistently below the national average. We expected that the rate of food insecurity in rural counties would be higher than in urban counties. We measured the incidence of food insecurity among rural and urban households in PA. We used the predicted trends produced by the United States Department of Agriculture Economic Research Service (USDA ERS), based on surveys given to individuals living in rural areas. We analyzed the USDA ERS data to compare the levels of food insecurity, considering the data for low and very low food security in rural counties in PA. To measure food insecurity in the urban counties, we used data provided by the hunger-relief organization Feeding America.To assess the relationship between food insecurity between rural and urban counties, we examined the data provided by census.gov in the following categories: income, household size, family determinants (head-of-household), and government assistance. These determinants were analyzed in comparison to food insecurity from the years 2015 to 2019 in both rural and urban households. Based on our data analysis between rural and urban areas, SNAP alone is not sufficient to address levels of food insecurity in rural areas. We found that about 1 in 7 rural households receive SNAP benefits compared to about 1 in 11 urban households. Yet the food insecurity rates were still higher in rural counties than in urban counties, at 11.82% and 10.76%, respectively. Overall, more households with women heads of household receive SNAP than households with men heads of households at the county, state, and national levels. Lastly, the average income in rural counties is over $10,000 less than the average in urban counties, and almost $10,000 less than the state average. Hopefully, these results will instill a sense of urgency that will influence new policies to support both rural and urban households in different capacities to decrease the food security gap among American households. Since PA tends to be below the national average for food insecurity, we hope that this will prompt action in above-average states as well.

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.

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.

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.

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.

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.

Purpose:Population-level environmental and socioeconomic factors may influence cancer burden within communities, particularly in rural and urban areas that may be differentially impacted by factors related to health care access.Methods:The University of Kansas (KU) Cancer Center serves a geographically large diverse region with 75% of its 123 counties classified as rural. Using County Health Rankings data and joinpoint regression, we examined trends in four factors related to the socioeconomic environment and health care access from 2009 to 2017 in rural and urban counties across the KU Cancer Center catchment area.Findings:The adult health uninsurance rate declined significantly in rural and urban counties across the catchment area (rural annual percent change [APC]=−5.96; 95% CI=[−7.71 to −4.17]; urban APC=−5.72; 95% CI=[−8.03 to −3.35]). Childhood poverty significantly decreased in rural counties over time (APC=−2.94; 95% CI=[−4.52 to −1.33]); in contrast, urban childhood poverty rates did not significantly change before 2012 (APC=3.68; 95% CI=[−15.12 to 26.65]), after which rates declined (APC=−5.89; 95% CI=[−10.01 to −1.58]). The number of primary care providers increased slightly but significantly in both rural and urban counties (APC=0.54; 95% CI=[0.28 to 0.80]), although urban counties had more primary care providers than rural areas (76.1 per 100K population vs. 57.1 per 100K population, respectively; p=0.009). Unemployment declined significantly faster in urban counties (APC=−10.33; 95% CI=[−12.16 to −8.47]) compared with rural counties (APC=−6.71; 95% CI=[−8.22 to −5.18]) (p=0.02).Conclusion:Our findings reveal potential disparities in systemic factors that may contribute to differences in cancer prevention, care, and survivorship in rural and urban regions.

There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors. County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density. In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000 persons, respectively. Over the past 2 decades, there was a significant increase in the percentage of orthopaedic surgeons in metropolitan counties (77% in 2000 vs 93% in 2019, P < 0.001) and in the proportion of orthopaedic surgeons 55 years and older (32% in 2000 vs 39% in 2019, P < 0.001). Orthopaedic surgeon density increased with increasing median home value (P < 0.001) and median household income (P < 0.001). Counties with a higher percentage of persons in poverty (P < 0.001) and higher unemployment rate (P < 0.001) and nonmetropolitan (P < 0.001) and rural (P < 0.001) counties had a lower density of orthopaedic surgeons. On multivariable analysis, a model consisting of median home value (P < 0.001), rural counties (P < 0.001), percentage of noninsured persons (P < 0.001), and percentage of foreign-born persons (P < 0.001) predicted orthopaedic surgeon density. Access to orthopaedic surgeons in the United States in rural areas is decreasing over time. County-level socioeconomic factors such as wealth and urbanization were found to be closely related with surgeon density.

Introduction: Stroke and other neurologic diseases may disproportionately affect persons in rural areas, and stroke-related mortality in rural counties has increased in recent years. Little is known about distribution and trends in neurologists and telestroke services in rural vs urban counties in the US. Methods: Volume and age distribution of neurologists in each county were determined using the AMA Physician Masterfile for each year 2010-2018. Neurologist density (per 100,000 persons) was estimated based on county-level population data. Telestroke units per county were identified using Area Health Resource files. Counties were classified as large metropolitan, medium or small metropolitan, or rural based on CDC WONDER designations. Results: From 2010-2018, mean (SD) neurologist density in rural counties decreased from 6.3 (21.6) to 5.9 (18.7) per 100,000 persons. A majority of rural counties experienced little to no change (0-5 per 100,000) in neurologist density over time. In contrast, neurologist density increased in large metropolitan counties from 31.1 (42.7) to 37.8 (52.1) per 100,000 and in medium/small metropolitan counties from 29.3 (67.8) to 32.2 (74.9) per 100,000. Over time, 42% of large metropolitan and 27% of medium/small metropolitan counties experienced &gt;10 per 100,000 longitudinal increases in neurologist density. The proportion of younger neurologists (&lt;35 or 35-44 years) appeared to increase in urban counties, while the proportion of older neurologists (≥65 years) relatively increased in rural counties. In 2018, telestroke units were available in 51%, 37%, and 18% of large metropolitan, medium/small metropolitan, and rural counties, respectively. Conclusions: Neurologist density has decreased in rural counties in the US, with a relative aging of existing neurologists in these settings. Four out of 5 rural counties do not have telestroke units. These data underscore the need to improve access to neurology in rural areas.

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

To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon. Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology). 420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015. Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions. Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers. This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.

While cancer deaths have decreased nationally, declines have been much slower in rural areas than in urban areas. Previous studies on rural cancer service capacity are limited to specific points along the cancer care continuum (eg screening, diagnosis or treatment) and require updating to capture the current rural health landscape since implementation of the 2010 Affordable Care Act in the USA. The association between current rural cancer service capacity across the cancer care continuum and cancer incidence and death is unclear. This cross-sectional study explored the association between breast cancer service capacity and incidence and mortality in Arizona's low populous counties. To measure county-level cancer capacity, clinical organizations operating within low populous areas of Arizona were surveyed to assess on-site breast cancer services provided (screening, diagnosis and treatment) and number of healthcare providers were pulled from Centers for Medicare and Medicaid Services National Provider Identifier database. The number of clinical sites and healthcare providers were converted to county-level per capita rates. Rural-Urban Continuum codes were used to designate rural or urban county status. Age-adjusted county-level breast cancer incidence and death rates from 2010 to 2016 were obtained from the Arizona Department of Health Services, Arizona Cancer Registry. Descriptive statistics were used to summarize the results. Multivariate regression was used to evaluate the association between cancer service capacity and incidence and mortality in 13 out of Arizona's 15 counties. Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p=0.02). Urban counties had more per capita pathologists (1.0) than rural counties (0) (p&le;0.01). In addition to zero pathologists, rural counties had zero medical oncologists. Rural county status was associated with a decrease in breast cancer incidence (&beta;=-20.1, 95% confidence interval: -37.2-3.1). While Arizona's sparsely populated rural counties may have more physical infrastructure per capita, these services are dispersed over vast geographic areas. They lack specialists providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving access to cancer preventive services and care. Compared to urban counties, rural county status was associated with lower detected breast cancer incidence rates although there were no statistically significant differences in breast cancer mortality. Other factors may contribute to rural-urban differences in breast cancer incidence. Future research should explore these factors and the association between cancer capacity and local resources because the use of county-level data represents a challenge in Arizona, where counties average over 19 425 km2 (7500 square miles).