APCblogit

CDC Stroke Registry Suggests Ways to Improve Care

In treating stroke, both physicians and the public can improve their roles, according to a 3-year analysis of results published in MMWR.

Data on some 60,000 patients with stroke from Georgia, Illinois, Massachusetts, and North Carolina were entered into the federally sponsored Paul Coverdell National Acute Stroke Registry between 2005 and 2007. Stroke types were as follows: hemorrhagic, 14%; ischemic, 56%; transient ischemic attack, 22%; and "ill-defined," 7%.

Researchers examined 10 treatment performance measures and their use among eligible patients. Among the results:

• Over a third of patients used private transportation rather than emergency medical services to get to the hospital.
• Only about 20% arrived at the hospital within 2 hours of symptom onset.
• Almost all got antithrombotic therapy at discharge (98%) and within 48 hours of admission (95%).
• About two thirds of those eligible received lipid-level testing.
• About a third of those eligible received tissue plasminogen activator.

LINK(S):

MMWR Surveillance Summaries article (Free)

The Shortage of Primary Care Services: Utilizing Nurse Practitioners and Physician Assistants to Relieve the Crisis

From Bob Blumm, MA, PA-C, DFAAPA:

It is evident that the American system of health care is in need of an
overhaul. Current figures indicate that there are over 46 million people who
are uninsured. This equates to 15% of our nation's citizens who may not be
able to access health care. The American College of Clinicians submits that
Physician Assistants (PAs) and Nurse Practitioners (NPs) already
significantly improve access to primary care services, but are underutilized
in our current health care delivery system. While fewer physicians are
choosing primary care, a new paradigm exists. But there has been a systemic
failure to recognize that the skills and knowledge of PAs and NPs makes them
well qualified to fill the role of primary care provider. Even though these
individuals demonstrate excellence in the provision of primary care,
barriers and territorial arguments rule. This is a perpetuation of the
belief that only physicians should or can provide primary care. While no
longer true, this belief creates barriers for other clinicians. Restrictions
need to be removed to allow all professionals to be utilized to their
fullest potential. PAs and NPs have been providing professional, high level,
primary care services for over forty years. There are over 200,000 of these
advanced practice clinicians (APCs) across the USA. Many have the experience
and are looking for the opportunity to provide health care in a way that
helps to heal the system.

Often decisions about patient care are driven by insurers based on profit
margins, not medical need. This has led to the dissatisfaction of many
providers, especially physicians, creating an exodus from the primary care
setting. This shortage is also complicated by the failure of policy makers
to recognize that APCs are already meeting primary care needs across the
country, and doing it well. Numerous studies which compare physician and APC
health care outcomes have shown either equivalent or superior outcomes for
NPs and PAs. Nurse Practitioners and Physician Assistants can and do staff
primary care clinics across the country.

There are multiple models which could be used to expand NP and PA services,
including the expansion of the retail clinic model to offer chronic illness
care as well as health care for acute illnesses, with a focus on prevention.
Clinicians would provide early screening and treatment for illnesses, which
when left untreated; have a significant financial impact on both the patient
and the system. Several channels may provide funding for these clinics. The
first would allow them to be outgrowths of current private sector practices.
The clinics could also be funded through government-sponsored grants,
similar to current programs such as the Public Health Service. Agreements
with consultants, specialists, hospitalists and local hospitals would
provide seamless coordination of care. The system would begin to provide
essential and critically needed services promptly, while policy makers
continue to evaluate and fine-tune the details. NP's and PA's are also
perfectly poised to play key roles in the emerging Medical Home model where
they can  provide astute patient-centered care.

As we look to the future, the ACC encourages those involved in medical
education to consider the benefits of the team approach to clinical
teaching. One strategy might be to allow NPs and PAs into primary care
residency programs that have been traditionally restricted to physicians and
use Medicare funding for part of that funding.  Another would be to develop
similar programs for NPs and PAs. For the APC who is new to the field or who
desires to move into primary health care, this would be a wonderful
opportunity to boost the number of providers in the primary care arena.
Another strategy might be to recruit and support returning war veterans who
wish to pursue careers in primary health care.

The American College of Clinicians will work toward the inclusion of both
NPs and PAs as full partners in the provision of primary care services. In
our country's difficult time, there is tremendous potential for growth of
all health care professions. We encourage all clinicians to become involved
in as many ways possible to improve the health of our nation.

Lancet Editorial Links Access to Birth Control, Benefits to the Environment

Providing no-cost contraception to women in developing countries could help slow population growth--and thus climate change -- according to an editorial by Leo Bryant of Marie Stopes International published Friday in the journal Lancet, the AP/Google News reports. According to the editorial, more than 200 million women worldwide want access to modern contraceptives but do not
have it, resulting in 76 million unintended pregnancies annually. Family planning is much less costly than typical methods used to fight climate change, the editorial states. It cites a British report that
found each $7 spent on basic family planning would translate into a one-ton reduction in carbon dioxide emissions (AP/Google News, 9/18).

Bryant -- the lead researcher on the World Health Organization study of climate change and population growth -- said that there is a stigma attached to contraception in both developing and developed countries that is hindering progress. According to the WHO study, nearly all of the world's 40 poorest countries have linked rapid population growth to an environmental impact, but only six have proposed steps to address the issue.

The world's population is on pace to increase by one-third -- to more than nine billion people -- by 2050, with 95% of that growth in developing countries, Reuters/Fox News reports. Bryant notes in the
editorial that most countries with good access to birth control experience a dramatic decrease in average family size within a generation.

Bryant said, "We are certainly not advocating that governments should start telling people how many children they can have." He added, "The ability to choose your family size ... is a fundamental human right. But lack of access to family planning means million of people in developing countries don't have that right" (Kelland, Reuters/Fox News,9/18).

"Michelle Obama on Health Care Reform and Women," Feministing: In a recent speech, first lady Michelle Obama said that President Obama's health care reform plan would create "true equality" for women. The blog entry includes an Associated Press video and a link to the full text of the speech (Feministing, 9/21).

Benefit From Over-Worked Residents?

From: Robert M. Blumm, MA, PA-C, DFAAPA :

Benefit From Over-Worked Residents?

by Jeff Reinke

 

A recent study shows that a 2003 reform of the length of resident on-duty hours could be connected to an increase in the rate of perioperative complications for patients treated for hip fractures. Among other things, this reform limited the resident workweek to 80 hours. This timeline corresponds to an increasing rate of worse outcomes seen in teaching hospitals, according to a study published in the September 2009 issue of The Journal of Bone and Joint Surgery (JBJS).

 

"The data suggests a statistically significant increase in selected complications after implementation of the duty-hour reforms in teaching hospitals. This may go against common assumptions regarding outcomes as they relate to the length of resident hours," said study lead author James M. Browne, MD, an orthopedic surgeon currently completing a fellowship in Rochester, MN. The study was performed at Duke University Medical Center.

 

On July 1, 2003, The Accreditation Council for Graduate Medical Education implemented a resident duty-hour reform for all medical and surgical residents in the U.S. Dr. Browne and his co-authors at Duke reviewed data from teaching and non-teaching hospitals for 48,430 patients treated for hip fractures in a nationwide inpatient sample database, reviewing groups from 2001 and 2002 before resident duty-hour reform, and from 2004 and 2005 after the reform.

 

This study sought to measure changes in the rate of patient death or resulting in-hospital complications since this reform. No increase in death rates was found, but increases in pneumonia, hematoma, transfusion, renal complications and non-routine discharge did occur.

 

In addition to an increase in the rate of medical complications, the study also notes an increase in length and cost of stay in teaching hospitals. Most would tend to agree with Dr. Browne's assumptions. "I think it would be premature for a patient to make any medical decisions based on the results of this study. Remember, this is limited to hip fracture outcomes tracked during a limited time period and does not take into account any improvements in delivery of care since 2005.

 

"Surgeons and policy-makers need more data to understand the full impact of these duty hour changes on our patients. As we consider any kind of reform, we must continue to keep the safe delivery of care that results in successful patient outcomes as our number one priority," said Dr. Browne.

 

It appears to be a thin line for teaching hospitals to walk. Although the benefits, both short and long-term, could be significant for repealing these reforms and getting as much as possible out of residents, the goal is to preserve these entry level surgeons, not burn them out. However, with an aging population and collection of baby-boomers hitting a period of their lives where they will need greater healthcare, are hospitals stretching resources too far by not asking for more hours out of residents?

 

Orthopedic procedures, one would assume, will continue to be in great demand as a surging population encounters more back and joint issues that may require a surgical fix not too far in the future. The ability to not only attend to this growing patient group, but ensure their procedures are done as well as possible, not only impacts the vitally basic elements of patient health and well-being, but the underlying principle of containing hospital costs and healthcare provider time in dealing with related negative outcomes.

 

The Footprints of an American Giant by Bob Blumm, MA, PA-C, DFAAPA

As I sit with my wife this morning watching the funeral of Senator Edward Kennedy, I am reminded that there are no party lines when it comes to the passing of great Americans. My wife mentioned that the two other Kennedys are remembered because of their tragically heroic lives and their premature deaths whereas Ted Kennedy will be remembered for a life of diligent, often tedious attention to detail. He used the gift denied his brothers, length of years, well.

For those of you who doubt his legacy, just look at the list of legislation’s that were sponsored and championed by this great man. Kennedy may have been labeled as a liberal by some but his legacy is a testament to his commitment and dedication to the disenchanted, the socially deprived and forgotten and the children of those that came through Ellis Island with the hope that America would indeed become a place of hope and provide opportunity to enjoy the freedoms that some dare to only hope for.

Ted Kennedy had a true passion for changing the lives of the citizens of this country and was perhaps the greatest giant in the proposed and passed laws related to Americans and healthcare. News commentator and former Congressman Joe Scarborough mentioned how he personally was obliged to leave the congress because of his son’s medical condition and he received no support of letters of concern from his fellow members of the House. He said that a short time later he received a package from Senator Ted Kennedy which had a beautifully concerned letter offering his assistance, a list of physicians and hospitals, as well as his concern and commitment to help him during his transition. He also sent an autographed large portrait of his brother, the late Robert Kennedy, who was Scarborough’s idol and hero.

Senator Kennedy was an example of a person who had a dream, was willing to plan, study, prepare and then put his feet to the treadmill to see that dream realized.  The title of this short commentary is “the Footprints of a Giant” and I ask us, as physician assistants and nurse practitioners, are we willing to stay the course and place action behind our beliefs and fill the footprints of this great man? It was a dream or a calling or a firm desire to change the lives of patients that brought us together into our respective professions and so often we become distracted by the mechanics of medicine that threaten to obstruct our efforts. Together, we have the opportunity to see our collective dreams fulfilled. This will require a great effort and a building of bridges between our professions as well as a commitment to look beyond our titles and instead to the recipients of the care that we can provide.

“My brother need not be idealized, or enlarged in his death beyond what he was in life, to be remembered simply as a good and decent man , who saw wrong and tried to right it, saw suffering and tried to heal it, saw war and tried to stop it” Ted Kennedy’s eulogy for his brother, Robert Kennedy.

As a seed is placed into the ground it requires nurturing, proper sunlight and adequate water and “hope” to see a tree. The definition of faith is “the substance of things hoped for and the evidence of things not seem.” I have faith that we, as committed advanced practice clinicians, can march together in Kennedy’s footprints and continue his mission.