Primary Care....Why We Need It & How Advanced Practice Nurses Can Help

Why People Need Access to Primary Care… One Potential Policy Solution-Independent Practice for Advanced Practice Nurses (Blog #5)

(Photo obtained from “TV or NOT TV blog, retrieved from http://www.tvornottv.net/2010/05/04/never-to-late-to-review-marcus-welby-m-d/ )

Portions of this blog entry were taken from a previously submitted health policy paper entitled “Independent Practice for Advanced Practice Nurses” by L. Pontious RN, BSN, MPH/MSN student

Does anyone remember Marcus Welby, M.D.? He was a fictional T.V. family practice physician , portrayed by actor Robert Young during the late 1960s and early 1970s.  He was the ultimate primary care provider, in many ways…warm, kind, tough (when necessary), compassionate, and a tireless advocate for his patients. Even though I have no scientific proof to back this assertion, I would guess that many physicians in practice today (of a certain age) were largely influenced by the media image of Dr. Welby when choosing their profession, and especially those that chose the specialty of family practice, or primary care.

Why is Primary Care Important to Health and Systems Delivering Care?        

Primary health care was defined in 1978 by the World Health Organization (WHO) as being

“essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination” (WHO & UNICEF, 1978).

            According to a 2005 Milbank Quarterly review of literature on health outcomes related to primary care, there is strong evidence that access to quality primary care providers, in adequate supply, prevents and decreases illness and death. Even after controlling for social and demographic factors (such as age, geographic locations, race, education, income, employment status, & exposure to pollution), and also controlling for lifestyle factors (such as smoking, obesity, & use of seatbelts), an adequate supply of primary care physicians was associated with an increased life span, lower infant mortality, lower all-cause mortality & reduced low-birth weight rates (Starfield, Shi, and Macinko, 2005).

            When comparing primary health care and health outcomes both within the U.S. and across several nations, this study also found that primary care, as opposed to specialty care, led to a “more equitable distribution of health in populations”, therefore reducing health disparities (Starfield, Shi, and Macinko, 2005).

The 2010 Patient Protection and Affordable Care Act (affectionately dubbed “Obamacare” by some political pundits) attempts to increase access to health insurance and health care for all U.S. citizens, specifically emphasizing prevention, primary care, and chronic disease management within a well-coordinated system of care (Kaiser Family Foundation, 2010, & http://www.healthcare.org/ ). With the expanded Medicaid, Medicare, and private insurance coverage mandated in the ACA, the Urban Institute’s Health Policy Center estimates that there will be an influx of tens of millions of newly insured patients into an already overtaxed primary health care system (Buettgens, Garrett, & Holahan, 2010).

Utilizing Advanced Practice Nurses to Bridge the Gap    

Advanced Practice Nurses (APNs, or APRNs) have many different defined roles within patient care. In layman’s terms, these registered nurses are academically prepared at a Master’s level or beyond, with focused specialty training for a specific population(s). They must pass national certification exams within their specialty area in order to be licensed to practice. Typically, they are responsible for preventative health promotion, diagnosis and treatment of specified conditions, and have some pharmacological prescriptive privileges. The four current APRN roles are certified nurse anesthetist (CRNA), certified nurse midwife (CNM), clinical nurse specialist, and certified nurse practitioner (APRN Joint Dialogue Group Report, 2008).  Currently, out of 400,000 primary care providers, at least 141,000 are advanced practice nurses, or approximately 8 percent of the 2.9 million registered nurses in the United States workforce (Naylor & Kurtzman, 2010). A recent literature review stated that all studies reviewed comparing health outcomes, patient satisfaction, and resource use between patients treated by nurse practitioners and physicians demonstrated that APRNs provided equivalent, if not better, care (Mundinger, Kane, & Lenz, et al., 2000).

Independence: Scope of Practice and Current Regulation          

In order for APRNs to be fully effective as primary care practitioners, many patient and nursing advocates and organizations argue that APRNs must be fully independent, able to diagnose and treat illnesses, anticipate and teach preventive health behaviors, prescribe medications, tests, and treatments as necessary, and admit patients to hospitals for care, without having to be directly supervised by a physician. Currently, there is “no uniform model of regulation of APRNs across the states” (APRN Joint Dialogue Group Report, 2008). The level of independence with which an APRN practices varies by state Nurse Practice Act (NPA). State regulations may include mandatory supervision and chart reviews by physician, as well as defining physical practice distance between the collaborating physician and the APRN. Additionally, each state may regulate what drugs and treatments may be prescribed by the APRN, independently, or with physician approval or oversight (Texas Public Policy Foundation, 2007).

The APRN Joint Dialogue Group Consensus Model

            A group of 33 national organizations representing the certification, accreditation, education, and regulation of APRNs was formed in 2004. A consensus model was compiled for the uniform regulation and licensure of APRNs throughout the United States and its territories. Published in July 2008, the Consensus Model for APRN Regulation defined the goals of centralizing regulation and legislation of APRNs, in order to ensure patient safety and expand patient access to care providers. The model recommended specific guidelines to move the competency assessment and regulation of APRNs to professional organizations within each specified practice area. The target date for implementation would be in the year 2015 (APRN Joint Dialogue Group, 2008). This model was endorsed by every major professional nursing organization, including the National Council of the State Boards of Nursing.

            Recent Publication supporting APRN’s independent practice

                On October 5, 2010, the Institute of Medicine (IOM), in conjunction with the Robert Wood Johnson Foundation, published a two year study report, entitled “The Future of Nursing: Leading Change, Advancing Health”. This document addressed barriers faced by the nursing profession, preventing rapid and effective response to current changes in the health care system. The report specifically discusses objectives set forth in the 2010 Affordable Care Act, with these “key messages”:                                                                                                                            

·         Nurses should practice to the full extent of their education & training.

·         Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

·         Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the U.S.

·         Effective workforce planning and policy making require better data collection and information infrastructure. (IOM, 2010).

The inconsistency of state regulations regarding scope of practice of advanced practice nurses (APN) is addressed.   As some states allow fully independent practice, prescriptive authority, and hospital admitting privileges, and this allows the most flexibility to address shortages in primary health care providers, this is the model recommended by the IOM.

The 2010 Affordable Care Act addresses increasing access to primary care providers, specifically including nurse practitioners. This increased access would be achieved by funding training programs with grants, and increasing numbers of nurse-managed health clinics (NMHCs) and federally qualified health centers (FQHC). These clinics would attempt to address medically underserved populations. However, the ACA does not address “independent practice” of nurse practitioners per se (see Subtitle E: Provisions relating to Title V, Public Health Service Act: Grants for FNP training program, see www.healthcare.gov).

Conclusion and Policy Suggestions

Due to worsening shortages in primary care providers across the United States, and in order to ease access to adequate numbers of these providers, there should be a nationwide adoption of the Consensus Model of APRN Regulation, allowing for full scope independent practice for advanced practice nurses. This model is endorsed by the State Nursing Boards and          all major nursing professional organizations. All available evidence suggests that this care is not only adequate, but equivalent to care by other providers, such as physicians. In order to increase the numbers of primary care providers anticipated to be needed with the implementation of health care reform, expansion of tuition assistance/loan forgiveness for primary care providers serving in underserved areas (including physicians, PAs, APRNs, & MPHs) should also be implemented.

As millions of previously uninsured persons enroll in primary care, prevention, wellness, and chronic disease management will hopefully be emphasized, therefore positively impacting public health on a large scale.

References

American Association of Colleges of Nursing. (2008). Consensus Model for APRN Regulation.

Retrieved October 1, 2010 from http://www.aacn.nche.edu/Education/pdf/APRNReport.pdf

American Association of Retired Persons (2010). Website http://www.aarp.org/research/

Bodenheimer, R. & Pham, H. H. (2010, May). Primary care: Current problems and proposed

 solutions. Health Affairs, 29(5), 799-805.

Buettgans, Garrett, & Holihan. (2010, December). America under the Affordable Care Act.

The Urban  Institute. Retrieved from http://www.urban.org/UploadedPDF/412267-america-under-aca.pdf

Institute of Medicine (2010, October). Report: The Future of Nursing. Leading Change, 

            Advancing Health. Retrieved from www.iom.edu/nursing

Kaiser Family Foundation. (2010, March). Focus on Health Care Reform: Summary of New

            Health Reform Law. Retrieved from www.kff.org

Mundiger, M. O., Kane, R. L., & Lenz, E. R. (2000). Primary care outcomes in patients treated

by nurse practitioners or physicians: A randomized trial. JAMA, 283(1), 59-68.

Naylor, M. D. & Kurtzmann, E. T. (2010, May).  The role of nurse practitioners in

reinventing primary care. Health Affairs, 29(5), 893-899.

Patient Protection and Affordable Care Act (2010). Website www.healthcare.gov

Phillips, S. J. (2010). 22^nd Annual Legislative Update. The Nurse Practitioner, 35 (1), 24-47.

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and

            health. The Milbank Quarterly, 83(3), p 457-502. Retrieved from

            http://www.jhsph.edu/bin/k/a/2005_MQ_Starfield.pdf

Stout, M. K. & Elton, J. (2007). Policy Brief: Comparing State Regulation of Nurse

Practitioners. Texas Public Policy Foundation. Retrieved October 1, 2020, from                             www.TexasPolicy.com.

Woo, B. (2006). Primary care: The best medicine? New England Journal of Medicine, 355(9),

            864-866.  

           

 

             

Outbreak Investigation at the Playboy Mansion

What’s cooking in the hot-tub at the Playboy mansion (Blog Assignment #4 “Free-Blog”)?

It seems that the mystery has been partially solved, as to the cause of the respiratory illness that plagued many conference attendees after a February 2011 Playboy Mansion fundraiser. The Los Angeles County Health Department presented their outbreak investigation results at the Centers for Disease Control and Prevention’s annual Epidemic Intelligence Service conference in Atlanta this month (L.A. times, see http://latimesblogs.latimes.com/lanow/2011/04/playboy-mansion-outbreak-bacteria-traced-to-whirlpool-spa.html).

While one would not want to think about what other types of infections might lurk in the Playboy Mansion hot tub (ewwww!), Legionella bacteria was isolated from the whirlpool spa, and from some of the sick people that attended the party. Overgrowths of Legionella, which is found naturally growing in aquatic environments, can cause Legionnaires’ disease, a reportable lung infection/pneumonia (CDC Legionellosis Resource Site, http://www.cdc.gov/legionella/top10.htm), or Pontiac fever, a milder lung infection without the pneumonia. As Legionella bacteria like warm water, it can be found in improperly disinfected hot tubs, large plumbing and air conditioning systems, and even hot water tanks (CDC Patient Fact Sheet, http://www.cdc.gov/legionella/patient_facts.htm ). The Playboy party was held in the enclosed cave-like pool area, known as the “Grotto”. There were several potential infection sources/reservoirs of Legionella, including a fog machine, pool, hot tub, and the air conditioning system. Legionellosis is spread by water vapor, not from person to person (luckily), as once it progresses to pneumonia, it has a case-fatality rate of 5-40%!

What was really interesting about this outbreak investigation was that the health department officials tracked down 439 people (of the 715 at the conference), in 30 different countries, using social media, such as Twitter, Facebook, and blogs. Online surveys were used to establish who was ill, what type of symptoms they had, & if they had been diagnosed by a healthcare provider with Legionellosis, pneumonia, or the flu. 79 people reported varying levels of respiratory illness (fever, cough, headache, chills, chest pain, shortness of breath) within the 2 to 14 days incubation period (http://www.forbes.com/feeds/ap/2011/04/15/entertainment-us-playboy-mansion-health-probe_8411341.html). The use of new technology to find hundreds of people in 30 different countries is amazing to me. In the recent past, this would not have been possible! I had not previously thought of the use of social media for epidemiological purposes, other than as a possible tool for health promotion, or public service announcements. This is an excellent example of quick thinking in a outbreak investigation, using existing resources. I have a newfound respect for the usefulness of Twitter and Facebook!

Forgotten Disclaimer!!!!

 “This blog was created for a graduate-level epidemiology project and does not officially represent the views of the University, professor, or other related entity.” Now, our university & professor are off the hook!!!

So What for the Gorilla-Feet Shoe Study?

So What about Gorilla Feet Shoes… (The End of Blog#3Assignment)

Why My Study on Injury Rates related to use of Barefoot-Gorilla-Feet Shoes-vs-Traditional Running Shoes Might Matter to Someone

What will change in the world if the marketing claims are true? That shoes that look like large primate feet are more kind to your feet & legs while running? This would not impact world health policy. It might not even make any of the health news. However, there are some interesting implications:

1)      If these shoes caused more harm than other traditional running shoes, a study might help pull them off the market, as proof of hazard or danger would be needed for consumer products advocates to act.

2)      If these shoes cause less harm than traditional running shoes, it might change marketing strategies & product development in a really large financial industry (in 2010, the sales figures for the sporting goods industry, which includes athletic shoes, topped $71 billion dollars (see the press release from the Sporting Goods Manufacturing Association, http://www.sgma.com/press/224_SGMA's-2010-State-of-the-Industry-Report-Released ).

3)      A study could potentially help consumers to make a healthy choice for their own bodies, with a decrease in running-related injuries (estimated 2008 totals from different industries on numbers of persons engaging in running as a sport or exercise: 35.9 to 41 million people, http://www.running.net/read_new/running-usas-state-sport-2009 ).

4)      As many studies do, my study could generate more inquiry into the biomechanics of running, or other related sports.

Ending Reflection

When new products are introduced into the consumer market, there is often an associated marketing campaign, designed to make one believe that this is a superior product with unique benefits. As health care advocates, we must carefully consider how the associated purchasing choices can affect the health of buyers. Large health consequences have been attached to past marketing campaigns, such as with the outcomes of early tobacco company ads such as this one:

While footwear choices might not be as dramatic as the “smoking ad/resulting lung disease & cancer example”, false or true, marketing can affect the health of millions, if not billions, of consumers.

More about Blog #3 Assignment: The Barefoot-like Running Shoes-vs-Traditional Running Shoes

Choosing a Study Population & Details on Carrying out the Study

Several parts of this study would need to be carefully defined. First, one would need to define the study population, from which the participants would be chosen, and then randomized to the exposed & unexposed groups.

Because men and women are physically built differently, which can lead to different running-related injuries (Chumanov, et al., 2008, link: http://www.engr.wisc.edu/groups/nmbl/pubs/cb08_chumanov.pdf ) an equal number of men and women in the study population sample would help clarify the injury differences (the results could be stratified, or categorized, by age and sex, for clarification of gender and age differences).

                             

Defining the population sample might be challenging, as there are runners of varyingly levels of fitness, agility, and with different habits (stretching-vs-not stretching). In order to try to make the sample a little more homogenous, I might choose healthy, uninjured recreational runners that have been running for 5 to 10 years, for a set range of miles per week, participating in a certain amount of longer distance competitive runs (such as half-marathons & marathons) per year. I also might chose some from different settings, such as different geographic areas (urban U.S., potentially from an East Coast city (such as New York) & from a West Coast city (such as Los Angeles), where there are likely to be larger running clubs, or training organizations, to recruit from.

Because this study could potentially be expensive, the sample sizes would need to be adequate enough to compare results, but not necessarily huge. Depending on my funding, I might choose 500 runners for the exposed group, and 500 runners for the unexposed group, with equal numbers of men and women.

All participants would be required to undergo an initial sports medicine physical, and rule out any past serious injuries or orthopedic surgeries, to qualify for the study. They would then be randomly assigned to the group with traditional shoes (no intervention, or unexposed), or to the “barefoot-type” shoes (exposed, intervention). All participants would be properly fitted for size in either type shoe by professionals.

Potential running-related injuries would need to be defined, such as hip bursitis, iliotibial band syndrome, hip stress fractures, pulled hamstrings, patellofemoral syndrome, plica syndrome, dislocating knee-cap, shin splints, exercise-induced compartment syndrome, ankle sprain, Achilles tendonitis, plantar fasciitis, foot stress fractures, and arch pain (Cluett, 2009, link: http://orthopedics.about.com/cs/sportsmedicine/a/runninginjury.htm).

Each group could be assigned to a sports medicine team (orthopedic physician, physical therapist, trainer, etc.). If injury should occur, the participants would need to go to their team for evaluation, and recording, of the injury, with some sort of standardization of diagnostic criteria. Criteria for dropping out of, or staying in, the study after injury would need to be decided on, as well as treatment protocols.

After the time period of the study/data collection has passed, then the rates of injury could be compared between the traditional shoe group & the barefoot-type shoe group.

The epidemiologists and statisticians analyzing the data should be objective, and without any preconceived ideas regarding the outcome, otherwise, there can be an analytic bias (Gordis, 2009, p 174).

Funding could be solicited from athletic shoe companies and sports medicine, sports training, and physical therapy groups (or at least they could supply the shoes, and the labor for the injury teams!). However, to rule out conflict of interest, the companies or employees of the shoe companies could not be involved in the study itself. For a less biased study, shoes would be independently purchased, to deflect any suspicion of conflict of interest (that is what Consumer Reports does!).

A blind study would be impossible, as the runners in each group would know what kind of shoes they were wearing, as well as that injuries were being monitored. 

Compliance & Other Challenges

As regular runners would not want to become injured, I feel that they would definitely report any injuries. However, if they did not like the shoes that they were issued, they might be more likely to drop out of the study, rather than to keep running in shoes they didn’t like! Also, because different shoe brands seem to fit different people, it would be hard to rule out differences in injuries between different brands of traditional shoes, unless one were to use only one brand (which might lead to another compliance issue!). In my purely anecdotal experience, runners can be very picky about their shoes!

References:

Chumanov, E.S., Wall-Scheffler, C., & Heiderscheit, B.C. (2008). Gender differences in walking

 and running on level and inclined surfaces. Clinical Biomechanics, 23,  1260–1268.

Retrieved from http://www.engr.wisc.edu/groups/nmbl/pubs/cb08_chumanov.pdf

Cluett, J. (2009). Running Injury: Information about common injuries in runners. About.com         Retrieved from http://orthopedics.about.com/cs/sportsmedicine/a/runninginjury.htm

Gordis, L. (2009). Epidemiology, 4^th ed. Philadelphia: Saunders Elsevier

How Does One Design a Study around the use of “Gorilla-Feet” Shoes? (Blog #3 continued...)

A scientific study design is part of this assignment. With the above topic in mind, how would one develop, or design, a study with these barefoot-like shoes?

If my hypothesis were “Running while wearing shoes such as the “Vibram-Five-Fingers” (shoes that simulate being barefoot), causes fewer injuries to feet, ankles, and joints than while using “traditional running shoes”, how would I set up a design to test it?

In this instance, my exposure would be wearing these “barefoot shoes” while running.

My disease (or desired outcome) would be fewer injuries associated with running.

Study Type

Choosing a study type is crucial, in that it should be appropriate for the situation. In this particular instance, I would want to compare an exposed (wearing the “barefoot-type” shoes while running) group, to an unexposed group (wearing traditional running shoes while running). Then, I would be monitoring each group over time to see if there is a difference in running-related injury rates between the two groups.

The study type that seems to be a “best fit” for this situation is a prospective cohort study (other names are concurrent cohort or longitudinal study (Gordis, chap 9, p 170). For even better evidence of causality, randomly assigning participants to the exposed & unexposed groups helps to decrease chances of other confounding factors (other factors that might secretly influence the outcome).

Why? A prospective study follows the exposed and unexposed samples over time to see if they develop the disease/outcome being monitored. In my fictional study, I would want to monitor my groups over a period of time that allows for the injuries to potentially develop. Not being an expert on sports injuries, I would do a literature review, and consult sports trainers and physicians that treat sports injuries, for narrowing this study time-frame down to something manageable. Challenges with prospective studies can be that, with following groups over long time periods, they can become expensive, and because of the longer time-frame, participants can be lost to drop-out, or attrition. This loss to follow-up can bias, or slant the results of, the study, potentially confusing interpretation (Gordis, chap 9, p 174).

Barefoot (or Almost Barefoot)...The newest fad? Or just Back to Nature?

What’s with the gorilla-feet shoes? (Blog #3 assignment)

If you walk around any college town or campus, you will see an abundance of a newer type of sport non-shoe with toes. The ones pictured above are a brand called “Vibram Five-Fingers”. More like a sock with a rubber/Vibram sole, wearers report that these non-shoes protect their feet from injury, but have the feel of going barefoot.

Why I’m interested in shoes….

When I was a kid & started to grow quickly, I developed some painful structural difficulties with my feet, required several major surgeries as a teenager. So, I was required to wear really awful, funky orthopedic shoes (I’m not kidding…really ugly…). As a young girl, this was both embarrassing & painful!

A couple of summers ago, in my mid-40’s, I had to have both my feet reconstructed, complete with titanium screws. Because I was casted on each foot for 8 weeks each, I spent several months on crutches, in therapy, and sitting in a chair with one foot, or the other, propped up, for about 6 months.

So, I’m no longer interested in shoes unless they are very comfortable…I’ve gotten over the ugly shoe phobia! And I wonder if the five-finger/barefoot shoes would be appropriate for a person with previously messed up, screwed-together feet like mine!

Recent news….

There have been some spotlighted barefoot runners in the Olympics & international competitions, such as in the 1980s Zola Budd (from South Africa, competing for Great Britain) and Abebe Bikila, an Ethiopian man who ran internationally in the 1960s & 1970s. Indigenous people from many countries have traditionally run long distances barefoot.

However, recently there has been an increase in public interest in barefoot running. Whether it is connected to an organic “back-to-nature” mentality, increased attention to running & sports injuries, or current fad, there have been numerous published articles suggesting that running without shoes might be safer, and less likely to cause injuries, than running in expensive, specially designed running shoes.

Article Links:

LA Times:

http://articles.latimes.com/2011/mar/18/sports/la-sp-la-marathon-20110319

Science Daily:

http://www.sciencedaily.com/releases/2010/01/100127134241.htm

Barefoot running website:

http://therunningbarefoot.com/

Blog on five-finger shoe use, models, and sizes:

http://www.justinowings.com/b/index.php/me/my-bare-feet-vibram-five-fingers-revi

“Your shoes are killing your feet….”

http://www.wired.com/wiredscience/2008/04/your-shoes-are/

“To run better, start by ditching your Nikes”

http://www.wired.com/wiredscience/2009/07/barefoot/

Harvard University’s skeletal biology lab

http://www.barefootrunning.fas.harvard.edu/

Why is barefoot supposedly better?

According to several of the above articles, such as the Science Daily 2010 above, and the Harvard skeletal biology lab, running in highly cushioned running shoes causes the runner to land on the heel (”heelstrike”), which causes more force to be absorbed by the body & its joints.

"Running barefoot or in minimal shoes is fun but uses different muscles," said Harvard professor Daniel Lieberman. "If you've been a heel-striker all your life, you have to transition slowly to build strength in your calf and foot muscles." (Credit: Image courtesy of Harvard University)

Barefoot running causes the runner to land on the ball of the foot, causing much less shock to the rest of the body. Much mention is made of the evolution of the human foot and body, as in, we are born without shoes and evolved to run without shoes. However, asphalt and concrete are modern constructions, much different to run, or walk on, than the grasslands or sand that humans evolved with as their primary walking surface.

Hence, the invention of the “barefoot shoe”, meant to feel as if one were barefoot, but with some protection from modern surfaces, potential parasitic infections, broken glass, gravel, and thorns.