Racial and Ethnic Disparities in Emergency Department Use Among Older Adults With Asthma and Primary Care Nurse Practitioner Work Environments

Background Older adults from specific racial and ethnic minoritized groups experience disproportionately higher asthma prevalence, morbidity, and mortality. They also often use emergency departments (EDs) to manage their asthma. High-quality primary care can improve asthma control and prevent ED use. Nurse practitioners (NPs) provide an increasing proportion of primary care to minoritized patients, yet often, they work in poor work environments that strain NP care. Objectives We examined whether racial and ethnic health disparities in ED visits among older adults with asthma are moderated by the NP work environment in primary care practices. Methods In 2018–2019, we used a cross-sectional design to collect survey data on NP work environments from 1,244 NPs in six geographically diverse states (i.e., Arizona, California, New Jersey, Pennsylvania, Texas, and Washington). We merged the survey data with 2018 Medicare claims data from 46,658 patients with asthma to assess the associations of all-cause and ambulatory care-sensitive conditions, ED visits with NPs’ work environment, and race and ethnicity using logistic regression. Results More than one third of patients with asthma visited the ED in 1 year, and a quarter of them had an ambulatory care-sensitive condition ED visit. Black and Hispanic patients were more likely than White patients to have all-cause and ambulatory care-sensitive condition ED visits. NP work environment moderated the association of race with all-cause and ambulatory care-sensitive condition ED visits among patients with asthma. Greater standardized NP work environment scores were associated with lower odds of all-cause and ambulatory care-sensitive condition ED visits between Black and White patients. Discussion Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with more favorable NP work environments. Preventing unnecessary ED visits among older adults with asthma is a likely benefit of favorable NP work environments. As the NP workforce grows, creating favorable work environments for NPs in primary care is vital for narrowing the health disparity gap.

Nursing: =√ One Purpose One Voice United Under Nursing Science

No abstract available

Acute Care Use Among Patients With Multiple Chronic Conditions Receiving Care From Nurse Practitioner Practices in Health Professional Shortage Areas

Background Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources. Objective We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas. Methods We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations. Results We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization. Discussion Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages.

Comparison of Weighting Methods to Understand Improved Outcomes Attributable to Public Health Nursing Interventions

Background The complex work of public health nurses (PHNs) specifically related to mental health assessment, intervention, and outcomes makes it difficult to quantify and evaluate the improvement in client outcomes attributable to their interventions. Objectives We examined heterogeneity across parents of infants served by PHNs receiving different interventions, compared the ability of traditional propensity scoring methods versus energy-balancing weight (EBW) techniques to adjust for the complex and stark differences in baseline characteristics among those receiving different interventions, and evaluated the causal effects of the quantity and variety of PHN interventions on client health and social outcomes. Methods This retrospective study of 4,109 clients used existing Omaha System data generated during the routine documentation of PHN home visit data. We estimated the effects of intervention by computing and comparing weighted averages of the outcomes within the different treatment groups using two weighting methods: (a) inverse probability of treatment (propensity score) weighting and (b) EBWs. Results Clients served by PHNs differed in baseline characteristics with clients with more signs/symptoms. Both weighting methods reduced heterogeneity in the sample. EBWs were more effective than inverse probability of treatment weighting in adjusting for multifaceted confounding and resulted in close balance of 105 baseline characteristics. Weighting the sample changed outcome patterns, especially when using EBWs. Clients who received more PHN interventions and a wider variety of them had improved knowledge, behavior, and status outcomes with no plateau over time, whereas the unweighted sample showed plateaus in outcomes over the course of home-visiting services. Discussion Causal analysis of PHN-generated data demonstrated PHN intervention effectiveness for clients with mental health signs/symptoms. EBWs are a promising tool for evaluating the true causal effect of PHN home-visiting interventions.

Tailored Nurse Support Program Promoting Positive Parenting and Family Preservation

Background Public health nurse home visiting is a promising approach for addressing the complex needs of families at risk of child maltreatment. The Colorado Nurse Support Program advances service provision by using evidence-based practices to provide tailored assessment and intervention to low-income, primiparous, and multiparous families with children under 18 years of age identified as high risk by county human service systems. Objectives This study aimed to test the effects of the Nurse Support Program on child protective services case characteristics between Nurse Support Program families and a demographically comparable reference group of families and evaluate changes in parenting outcomes from pre- to postprogram involvement for Nurse Support Program families. Methods We used a matched comparison group quasi-experimental design in which families in the Nurse Support Program (n = 48) were compared to families (n = 150) who were identified using administrative data from Colorado’s Comprehensive Child Welfare Information System. Outcomes were child protective case characteristics (child protection referrals, open assessments, founded assessments, open cases, and children’s placement in out-of-home care) and parenting outcomes. Results Nurse Support Program families were less likely to have a child protection case opened or have their child placed in out-of-home care. There were no significant between-group differences in child protection referrals, open assessments, or founded assessments. Families in the Nurse Support Program showed improvements in parenting outcomes over time. Discussion Findings suggest that the Nurse Support Program is a successful public health nurse home-visiting approach to promote positive parenting and family preservation among families with complex needs. Implementing tailored public health nurse home-visiting programs, such as the Nurse Support Program, should continue to be evaluated and supported to mitigate the public health risk of child maltreatment.