AMA: 3-year study of NPs in the ED: Worse outcomes, higher costs

[LKPAC]

Looks like AMA is going after NPs.  Are we next?

 

3-year study of NPs in the ED: Worse outcomes, higher costs

[ventana]

it is the start of the crumbling of NP

They are going to be facing many challenges - you can't do a DLO 1-2 yr program, observe 400 hours of patient contact and have any clue how to practice medicine

I think AMA should study NP's more - I would not mind them also studying PAs as long as they can report the data separately - no better data then a study by AMA that says NP<PA=MD/DO

 

Few recent cases to back this up

My most recent case was a COVID + Hep C (with cirrhosis and ascites unvaccinated)  patient seen on Friday in UC by an NP - they literally could not figure out what to do so said follow up with your PCP (me) on Monday - yup wasted the entire weekend and then made me pick up the pieces Monday morning.  Darn lucky the patient did not die over the weekend. (wrong on so many levels)  

One before that seen in UC by an NP for "decreased vision"  obese HTN late 30's male Thursday.   PE documented normal sclera and slight injection of conjunctivae with no DC present.  Dx with "conjunctivitis" and sent home with ilotycin.  Patient knew something was up and self referred to OPTHO next day and Dx with retinal vein occlusion and almost total loss of vision.  I spoke to the NP after the fact and their question was "what tipped you off"    I asked if they did acuity or talked to the patient about what their actual CC was - Nope and Nope  "we were busy that day"   Granted the outcome might not have changed but this NP had only a single Dx in their Ddx.... and it was wrong.  They could not even come up with a Ddx on the phone with me and were asking questions like a 1rst year PA-S.  

 

 

Okay I will climb down from my soap box now.... rant over

[EMEDPA]

I am working with an RN today who is finishing their psych NP this month, doing most of the coursework while at work as an ED RN.

2 years part time while working full time:

https://www.mcphs.edu/academics/school-of-nursing/nursing/psychiatric-mental-health-nurse-practitioner-msn?inquiryid=af377f14-68ec-d691-6a3e-b15b9157b327&transactionid=e1bddc35-c31a-cd67-3d47-ec3f21ef0bbf

online coursework

450 hrs of telemedicine psych visits done over zoom with a psych np preceptor(also on the zoom calls). 

After they graduate they anticipate they will make 400k their first yr as a psych np doing 100% telemedicine visits from a home office. 

hard to believe they would give up the abuse they take as an ED RN for $40/hr for this....

[SedRate]

2 hours ago, EMEDPA said:

I am working with an RN today who is finishing their psych NP this month, doing most of the coursework while at work as an ED RN.

2 years part time while working full time:

https://www.mcphs.edu/academics/school-of-nursing/nursing/psychiatric-mental-health-nurse-practitioner-msn?inquiryid=af377f14-68ec-d691-6a3e-b15b9157b327&transactionid=e1bddc35-c31a-cd67-3d47-ec3f21ef0bbf

online coursework

450 hrs of telemedicine psych visits done over zoom with a psych np preceptor(also on the zoom calls). 

After they graduate they anticipate they will make 400k their first yr as a psych np doing 100% telemedicine visits from a home office. 

hard to believe they would give up the abuse they take as an ED RN for $40/hr for this....

Wow

[Mayamom]

On 2/11/2023 at 7:53 AM, ventana said:

My most recent case was a COVID + Hep C (with cirrhosis and ascites unvaccinated)  patient seen on Friday in UC by an NP - they literally could not figure out what to do so said follow up with your PCP (me) on Monday - yup wasted the entire weekend and then made me pick up the pieces Monday morning.  Darn lucky the patient did not die over the weekend. (wrong on so many levels) 

What did you do differently?   Admit?  Paxlovid?   I can imagine they were hesitant to prescribe paxlovid due to advanced liver disease. 

[ventana]

45 minutes ago, Mayamom said:

What did you do differently?   Admit?  Paxlovid?   I can imagine they were hesitant to prescribe paxlovid due to advanced liver disease. 

Whole cluster.  Ended up with Paxlovid after talking with transplant guy who overruled pharmacy.  
point was the NP in UC should have done this on Friday when he was there with cobid complaints.  Not punt to Monday.  Had he died over weekend it would have been “open up your checkbook and write the million dollar check”.  All because “I didn’t know what to do”. Pretty much verbatim from the chart.   

[ventana]

6 hours ago, EMEDPA said:

I am working with an RN today who is finishing their psych NP this month, doing most of the coursework while at work as an ED RN.

2 years part time while working full time:

https://www.mcphs.edu/academics/school-of-nursing/nursing/psychiatric-mental-health-nurse-practitioner-msn?inquiryid=af377f14-68ec-d691-6a3e-b15b9157b327&transactionid=e1bddc35-c31a-cd67-3d47-ec3f21ef0bbf

online coursework

450 hrs of telemedicine psych visits done over zoom with a psych np preceptor(also on the zoom calls). 

After they graduate they anticipate they will make 400k their first yr as a psych np doing 100% telemedicine visits from a home office. 

hard to believe they would give up the abuse they take as an ED RN for $40/hr for this....

400k.  Holllyyyyyy cow.    
they are going to seriously screw up some people.  

[EMEDPA]

1 hour ago, ventana said:

400k.  Holllyyyyyy cow.    
they are going to seriously screw up some people.  

6 ten min appts/hr, say 6 hrs/day. 36 "clients"/day, 5 days a week.  180 pts/week. .  Those of you who are RVU gurus do the math. 

Oprah and I could do this job : " YOU get zoloft and YOU get zoloft and YOU get zoloft!

[iconic]

That's extremely unusual. 200k for telepsych would be on the extreme high side for NPs. The problem is that non psych-RNs are doing psych NP programs and finding out that they absolutely hate psych (and that salaries are really not that high in most places and certainly not in telehealth). There's really not an unlimited supply of patients and even pill mills do 15 min apps while good places do 20-30 min follow ups 

Edited February 13, 2023 by iconic

[EMEDPA]

48 minutes ago, iconic said:

That's extremely unusual. 200k for telepsych would be on the extreme high side for NPs. The problem is that non psych-RNs are doing psych NP programs and finding out that they absolutely hate psych (and that salaries are really not that high in most places and certainly not in telehealth). There's really not an unlimited supply of patients and even pill mills do 15 min apps while good places do 20-30 min follow ups 

depends how you define a psych pt I guess. I believe most of the programs claim that you can do mental health and addiction medicine with their <500 hr course. 

Looks like bariatric psych is a thing now too:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8783166/

Lots of folks out there with anxiety, depression, addiction issues, and obesity. 

YOU ALL GET ZOLOFT! ( and you, generic addict sir,  also get suboxone and antabuse). 

[Boatswain2PA]

3 hours ago, ventana said:

Had he died over weekend it would have been “open up your checkbook and write the million dollar check”.

You are exaggerating again.  It's not like Paxlovid is some miracle cure that keeps people from dying from covid.

Slight decrease in hospitalizations is, I believe, all it is supposed to do.

[rev ronin]

5 hours ago, EMEDPA said:

6 ten min appts/hr, say 6 hrs/day. 36 "clients"/day, 5 days a week.  180 pts/week. .  Those of you who are RVU gurus do the math.

Naah, you don't even need that. Don't look at what PAs earn per hour--look at what insurance plans pay per code. If you're your own credentialed entity, you get all of that, less overhead.  Telemedicine from home? Not that much overhead. Running the numbers, hiring a psych ARNP for my clinic, they could easily end up taking home $200k for 1.0 FTE without even trying hard.

(And yes, by those numbers, 180 99213s would be just shy of $30k/week for an NP in my worker's comp world.... but that's just nuts.)

[LT_Oneal_PAC]

The study is dubious at best. Quasi experimental with no randomization. Highly complicated mathematical analysis. Only studied weekday and day time hours. They excluded places where PAs primarily worked, who may have a higher standard for what NPs they hire. They admit no difference in admission rates but still had increased preventable hospitalization, which is odd. Doesn’t compare pre and post full practice authority. Most suspicious is they state that NPs did not perform better with experience, though I’m not even sure how they developed this conclusion based on their methodology, and goes against common sense, but justify it stating they have less “innate” ability that suggests they are just dumber than physicians and training has nothing to do with it. 
 

Based on their results I would even say that the difference is minimal and could likely be eliminated with some EM specific training like a year long residency.
 

this is political fodder and little more to me. If we were smart we do our own study before the AMA does it for us. 

[sas5814]

The problem with any AMA study is they begin with a premise and then set out to prove it. Their methodology is garbage.

They used to state all kinds of opinions when we we co-testifying in committee. I liked to go first and ask the committee to ask them for proof of anything they claimed and then be suspicious of the validity. I would leave them with about 10-12 studies showing the effectiveness of PAs.

They have been coming after NPs for years and they are after us too. They always have been. Usually they do it by dividing the world into "physician" and "not a physician" which I have pointed out many times to many people makes their "data" complete trash.

 

[kettle]

3 hours ago, sas5814 said:

The problem with any AMA study is they begin with a premise and then set out to prove it. Their methodology is garbage

 

Wait! What??? So in my research I'm not supposed to know the outcome before the hypothesis??? This is mind boggling

When I was in residency ACEP came out with their forecast of EM MD jobs, the MD residents were cool with me knowing that I was going rural but they were not that kind to my cohorts staying metro. Turns out the sky wasn't falling....

[ventana]

On 2/13/2023 at 12:23 AM, Boatswain2PA said:

You are exaggerating again.  It's not like Paxlovid is some miracle cure that keeps people from dying from covid.

Slight decrease in hospitalizations is, I believe, all it is supposed to do.

doesn't matter

in this state the plaintiffs win big

no way to say that if he had died it was not contributed to by the lack of treatment by the NP - you don't turn away someone with an acute issue and say see you in three days

[Boatswain2PA]

7 minutes ago, ventana said:

you don't turn away someone with an acute issue and say see you in three days

Acute does not equal emergent.

Covid these days rarely causes an emergent safety to health.  Usually just an acute runny nose.

There are enough real life examples of poor care by NPs; we don't need to exaggerate this into something it isn't.

[EMEDPA]

On 2/13/2023 at 6:46 AM, LT_Oneal_PAC said:

 If we were smart we do our own study before the AMA does it for us. 

There was a study of EMPAs done maybe 15-20 years ago when American PAs started working in the UK NHS ED's. It showed PAs saw more patients/hr, documented better, AND required less supervision than senior year EM residents. 

[Reality Check 2]

 

At least it says comparable and doesn't drag non physicians....................

 

 

[EMEDPA]

Role of Physician Assistants in the accident and emergency departments in the UK
Ansari U, Ansari M, Gipson K. Accident and Emergency Department; Warwick Hospital, UK
Published in 11th International Conference on Emergency Medicine, Halifax, Nova SCotia, Canada, June 3-7 2006 and Journal of Canadian Emergency Medicine, May 2006, Vol 8 No 3 (Suppl) P583

Introduction: The Accident and Emergency departments in the UK are under severe pressure to expand their staffing levels in a bid to try and comply with the 98% target for 4-hour waiting times set by the government. Increasing staffing levels is proving to be very difficult when a majority of Staff Grades have already left or are leaving to become General Practitioners for financial gains and better working hours. This combined with a limited number of FY2 doctors being allowed to work in Accident and Emergency departments poses new challenges to staffing within Accident and Emergency. The objective of this study was to evaluate the training requirements, GMC regulations and supervision required to perform a suitable role in Accident and EMergency following the appointment of two Physician Assistants at City Hospital, Birmingham. Methods: The activities of two Physician Assistants at City Hospital were monitored for two months. All case records were reviewed and the number and type of patients seen by the assistants recorded. These were then compared with the records of those patients seen by Senior House Officers. Monitored information included number of patients seen, type of patients seen as well as the quality of the notes. Results: On average, Physician Assistants at City Hospital treated 3-5 patients/hour compared to 1.5-2.5/hour seen by Senior House Officers. Physician Assistants were able to deal with most medical, surgical, orthopaedic and gynaecological problems with minimal supervision. The medical records revealed that documentation was better by Physician Assistants. Conclusion: Senior Physician Assistants from the USA are an effective way to improve staffing within Accident and Emergency Departments with the UK. Physician Assistants saw more patients and required less supervision than Senior House Officers. Physician Assistants proved to be a cost effective method of supporting Accident and Emergency doctors at City Hospital, Birmingham.

[ventana]

7 hours ago, Boatswain2PA said:

Acute does not equal emergent.

Covid these days rarely causes an emergent safety to health.  Usually just an acute runny nose.

There are enough real life examples of poor care by NPs; we don't need to exaggerate this into something it isn't.

Boats. Did you read my post with the clinical hx?  Cirrhosis with ascites.   This is not your run of the mill patient he is one sick guy to begin with.  Covid could have killed him.  Transplant team were very worried about him.  We had nurses visiting twice a day.  Labs daily with critical values.   Please don’t lecture me on something clinical you clearly know nothing about the specifics.   It was indefensible the Np d/c to home.  Even by our own hospitals guidelines it was the wrong choice.  

[ventana]

6 hours ago, Reality Check 2 said:

 

At least it says comparable and doesn't drag non physicians....................

 

 

Concern is collection years.  This was before the flooding of the market with DLO NP’s.  
 

I would love to see an honest data driven study right now because I think it would demonstrate worse outcomes specifically with Newer NP who had an online training.  

[Boatswain2PA]

11 hours ago, ventana said:

Boats. Did you read my post with the clinical hx?  Cirrhosis with ascites.   This is not your run of the mill patient he is one sick guy to begin with.  Covid could have killed him.  Transplant team were very worried about him.  We had nurses visiting twice a day.  Labs daily with critical values.   Please don’t lecture me on something clinical you clearly know nothing about the specifics.   It was indefensible the Np d/c to home.  Even by our own hospitals guidelines it was the wrong choice.  

Your clinical hx didn't say anything about patient condition.

Was he tachy to 130 with sats in 70s on NRB needing intubated and admitted to ICU?  Then paint that picture.

You never said "labs with critical values"....but were these covid related labs?  Blood gas showing marked hypoxia, neutropenia, ddimer at 10k?  Or just chronic "critical labs" from his cirrhosis?  

Or was he, like most people, simply a guy with multiple comorbidities preventing with a runny nose and got tested for covid, and sent home.  No big deal (until some exaggerates it).

"Could have killed him" is just more conflating.  He "could have" acquired MRSA from the hospitalization and died from that.

There are enough examples of poor NP practice that we don't need to exaggerate to find them.

 

[ventana]

Boats 

you are incorrect 

it was clearly stated in my post.  

please reread posts to learn timeline of things as you are making statements that are contradictory with the typed posts right above for everyone to see. 
 

instead of always picking a fight how about reading the posts first?

[Boatswain2PA]

On 2/11/2023 at 6:53 AM, ventana said:

My most recent case was a COVID + Hep C (with cirrhosis and ascites unvaccinated)  patient seen on Friday in UC by an NP - they literally could not figure out what to do so said follow up with your PCP (me) on Monday - yup wasted the entire weekend and then made me pick up the pieces Monday morning.  Darn lucky the patient did not die over the weekend. (wrong on so many levels)  

This is your original note.

No indication the pt was sick, just covid + hep c and wasn't rx'd paxlovid.