The Scope of Practice of Nurse Practitioners and Physician Assistants on Inpatient Medicine Services in the Veterans Health Administration

1VA Boston Healthcare System, Center for Organization, Leadership, and Management Research, Boston, MA
2The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA, Iowa City, IA

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97672

Background:

Nurse Practitioners (NPs) and Physician Assistants (PAs) have been shown to be cost–effective substitutes for physicians with similar outcomes in primary care and surgical settings. The Veterans Health Administration (VHA) is one of the earliest and largest employers of NPs and is the largest single employer of PAs in the US. 42% of academic medical centers’ hospitalist medicine services use NPs and 31% use PAs. However little is known about the role of NPs and PAs in either of these settings.

Methods:

Observational cross–sectional cohort study with IRB approval. We surveyed 123 Chiefs of Medicine on various aspects of the quality of inpatient medicine care at their VHA medical centers (VA). We report results for a subset of the survey questions that address the scope of practice of NPs and PAs on inpatient medicine services in the VHA. All analyses were done using STATA version 12.

Results:

61 of 123 (49.6%) VA inpatient medicine services reported having NPs and PAs. Of those 61 services, 27 (44.3%) had NPs only, 15 (24.6%) had PAs only and 19 (31.2%) had both NPs and PAs. FTEE for NPs ranged from 0.5 – 7 and for PAs from 1–4. 82% of NPs and PA’s worked in inpatient wards while 23.1% worked in step–down units. NPs functioned at least somewhat autonomously in 58.9% and PAs functioned at least somewhat autonomously in 65.4% of the services while 27.0% worked in a role closer to ward assistant. NPs and PAs performed a variety of tasks (Table 1). NPs worked directly with hospitalists in 63.4% and PAs in 82.1% of the services. 34.1% of NPs and 50.0% of PAs championed Quality Improvement (QI) activities. There were some differences in tasks, with a higher proportion of services reporting PAs than NPs performing procedures (50.0% versus 22.0% p=.02) and teaching non–physicians (50.0% versus 24.4%, P=.04). While most worked weekdays, more PAs than NPs worked federal holidays (32.1% versus 7.9%, p=.02) and weekends (32.1% versus 13.2% p=.08). 8% of NPs and 18% of PAs worked nights (p=0.27). Caseloads were similar among the two with most handling a caseload of 4–10 patients with a mean of 6.5 patients per provider.

Conclusions:

NPs and PAs commonly work on inpatient medicine services in a variety of roles in the VHA. They often work autonomously as well as with hospitalists. They are also engaged in a variety of non–clinical activities such as QI. There are few significant differences between the roles of NPs and PAs on inpatient medicine services. Given their different training, experience and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs. The results of this study may not be generalizable to non–VHA medicine services.

Table 1Tasks performed by NPs and PAs on VA inpatient medicine services

  NP N=41 PA N=28 p–value†
H&Ps 31 (76%) 25 (89%) 0.22
Progress notes 31 (76%) 24 (86%) 0.37
Write orders 34 (83%) 26 (93%) 0.29
Perform procedures 9 (22%) 14 (50%) 0.02
Coordinate d/c plan 33 (81%) 26 (93%) 0.18
Communicate with consultants 33 (81%) 24 (86%) 0.75
Communicate with PCP 31 (76%) 20 (71%) 0.78
Work with hospitalists 26 (63%) 23 (82%) 0.18
Champion QI 14 (34%) 14 (50%) 0.22
Research 1 (2%) 1 (4%) 1.00
Teach non–physician students 10 (24%) 14 (50%) 0.04
Committees 16 (39%) 16 (57%) 0.15
Other 6 (15%) 0 (0%) 0.04
†Two–tailed Fisher tests.

To cite this abstract:

Kartha A, Benzer J, Burgess J, Glasgow J, Hockenberry J, Restuccia J, Kaboli P, Johnson S. The Scope of Practice of Nurse Practitioners and Physician Assistants on Inpatient Medicine Services in the Veterans Health Administration. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97672. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/the-scope-of-practice-of-nurse-practitioners-and-physician-assistants-on-inpatient-medicine-services-in-the-veterans-health-administration/. Accessed November 20, 2019.

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