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

[rev ronin]

5 hours ago, Boatswain2PA said:

This is your original note.

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

Ascites is usually an indication a patient is at least somewhat sick. I mean, maybe you're dealing with really sick people all the time and ascites is no big deal to you, but when I see "ascites" in a writeup, I expect that it's pronounced enough to indicate that it's a clinically significant finding, and Ventana even repeated that after you challenged him.

You've wasted several back-and-forth posts arguing about something that Ventana obviously felt was serious enough to mention, and instead of listening when he tells you, again, why he assessed the seriousness that way, you've responded with hypotheticals irrelevant to the original discussion.

Please conduct yourself better.

[Boatswain2PA]

1 hour ago, rev ronin said:

Ascites is usually an indication a patient is at least somewhat sick. I mean, maybe you're dealing with really sick people all the time and ascites is no big deal to you, but when I see "ascites" in a writeup, I expect that it's pronounced enough to indicate that it's a clinically significant finding, and Ventana even repeated that after you challenged him.

You've wasted several back-and-forth posts arguing about something that Ventana obviously felt was serious enough to mention, and instead of listening when he tells you, again, why he assessed the seriousness that way, you've responded with hypotheticals irrelevant to the original discussion.

Please conduct yourself better.

I sent a guy with ascites home 2 hours ago.  Chronic liver condition (this time cancer with liver mets instead of hep C).

Ventana can "feel" whatever he wants.  But when he throws up that not giving paxlovid made him "lucky the guy lived through the weekend" and risked "opening up the checkbook and writing that million dollar check" it is just sheer exaggeration.

Maybe someone smarter than me can correct me if I'm wrong here, but I think Paxlovid only promises a slight decrease in hospitalizations, but had no improvement on mortality.

Edited February 16, 2023 by Boatswain2PA

[newton9686]

I am team Boats. But I am biased because I live near the coast and love boats, specifically teal T tops. Here is my quick literature review

"Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge" showed a significant reduction in death (hazard ratio 0.21) in those that were 65 years and older. You were actually more likely to die if you received Nirmatelvir if you were under the age of 65 (hazard ratio 1.32).

The combo therapy in the EPIC HR Trial reduced the risk of hospitalization or death by 89 percent in the unvaccinated at 28 days which was significant as well. 

Paxlovid however is not recommended for advanced liver cirrhosis (Child-Pugh Class C). Which they may have been if you said they had "multiple critical values". Paxlovid is also only recommended if symptom onset is less than 5 days as well. It was not clear if pt was past this point when they saw the UC NP. 

Either way I agree not enough information was provided to make a decision on what was the correct decision and if the NP, however incompetent they may be failed to meet the standard of care. I have a feeling symptoms have been either going on longer than 5 days or Child-Pugh class was C or higher thus Paxlovid would not be recommended per UTD and the NP would not of been liable. Ascites, hep-C and COVID + is not enough information as I care for patients who are not critically sick with ascites all the time.  Thus the original author should not of been upset when two PAs challenged him/her on whether or not they were overreacting when they provided very limited information that did not make it obvious a NP failed to meet standard of care. 

 

[rev ronin]

7 hours ago, Boatswain2PA said:

I sent a guy with ascites home 2 hours ago.  Chronic liver condition (this time cancer with liver mets instead of hep C).

Ventana can "feel" whatever he wants.  But when he throws up that not giving paxlovid made him "lucky the guy lived through the weekend" and risked "opening up the checkbook and writing that million dollar check" it is just sheer exaggeration.

Maybe someone smarter than me can correct me if I'm wrong here, but I think Paxlovid only promises a slight decrease in hospitalizations, but had no improvement on mortality.

Come back in a week when you feel like behaving better.

[ventana]

2 hours ago, newton9686 said:

I am team Boats. But I am biased because I live near the coast and love boats, specifically teal T tops. Here is my quick literature review

"Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge" showed a significant reduction in death (hazard ratio 0.21) in those that were 65 years and older. You were actually more likely to die if you received Nirmatelvir if you were under the age of 65 (hazard ratio 1.32).

The combo therapy in the EPIC HR Trial reduced the risk of hospitalization or death by 89 percent in the unvaccinated at 28 days which was significant as well. 

Paxlovid however is not recommended for advanced liver cirrhosis (Child-Pugh Class C). Which they may have been if you said they had "multiple critical values". Paxlovid is also only recommended if symptom onset is less than 5 days as well. It was not clear if pt was past this point when they saw the UC NP. 

Either way I agree not enough information was provided to make a decision on what was the correct decision and if the NP, however incompetent they may be failed to meet the standard of care. I have a feeling symptoms have been either going on longer than 5 days or Child-Pugh class was C or higher thus Paxlovid would not be recommended per UTD and the NP would not of been liable. Ascites, hep-C and COVID + is not enough information as I care for patients who are not critically sick with ascites all the time.  Thus the original author should not of been upset when two PAs challenged him/her on whether or not they were overreacting when they provided very limited information that did not make it obvious a NP failed to meet standard of care. 

 

 

this is my point

 

The NP did NOTHING but sent them home to follow with me on Monday, no labs, no further assessment.

 

C-P was calculated by myself monday after doing STAT labs (NP had not done any labs - I had to order them stat)

 

 

My whole point is that in this case (Admittedly details were left out on purpose as it is not a case review) to send a person home who just tested + for covid who has every indication for Paxlovid with the A/P of COVID f/u with PCP in 3 days is simply malpractice in my mind.  Treatments are time sensitive, this patient had a commodity which warranted slowing down and making sure you were doing the right thing.  Not just punting to PCP.   There is no guarantee that this patient was going to follow up as requested and the NP had not done anything (like involving case management) to ensure follow up.    It took me calling repeatedly to get a hold of patient and then get labs, then do all the leg work to get treated......

 

To be clear the 'critical labs" was plt at 21 that slowly climbed with treatment back to his baseline around 50.  The NP in UC didn't know this they didn't check a CBC  or ANY labs (on an acutely ill comorbid patient)   Yet another example of poor inferior care.

 

 

Sorry folks but this one is pretty clear (Admin, local doc's and Transplant and pharmacy all agree it was handled wrong)

[newton9686]

While not a case review. If you are going to talk trash about a person based on their credentials and want everyone to agree with you, its preferable to provide enough detail to make it obvious why they were wrong. I.e diagnosed gastroenteritis, later appendicitis or diagnosed a UTI in a 40 y/o male with suprapubic pain with multiple ER visits, later diagnosed with diverticular abscess and lucky didn't get a poop bag. And if you don't provide enough details don't be surprised someone has a different idea that you, especially with COVID when most of the treatments for the first year or two were not effective and the details you gave did not make it 100% obvious you were right. 

Otherwise we are no better than the article on CNN making assumptions about PA/NPs in the ED and there example was a lady that went to the ED 3x for bleeding during pregnancy and eventually had a spontaneous abortion and made the assumption that a ER physician could of magically done something different to avoid this undoubtedly inevitable outcome. 

Also should we even really be talking crap about our colleagues? As a nocturnist PA (who is also going to medical school). I have cleaned up crap from ER, ICU, ER and hospitalist providers alike of all credentials. Granted there are cultprits who are more likely to leave me a mess. However sometimes its better to just focus on the fact that everyone is overwhelmed, overworked, underpaid and under appreciated and in order to make it through the day have  to cut corners on occasion. And its easy to get a chip on your shoulder when you get ripped into for a mistake you make, but fix a larger mistake that goes unnoticed because someone has a certain credential. But at the end of the day we need each other and there is going to be more variability in PAs/NPs compared to MD/DOs and that's why we need 1 year required fellowships for all new PA/NPs to best assure we are meeting the standards of care and optimizing the impact they make on patients.  Also decreasing burnout and workload would help as well as like I said most of the mistakes I make is because I'm being asked to do the work of 2 or 3 providers and something falls through the cracks. 

[ventana]

1 hour ago, newton9686 said:

While not a case review. If you are going to talk trash about a person based on their credentials and want everyone to agree with you, its preferable to provide enough detail to make it obvious why they were wrong. I.e diagnosed gastroenteritis, later appendicitis or diagnosed a UTI in a 40 y/o male with suprapubic pain with multiple ER visits, later diagnosed with diverticular abscess and lucky didn't get a poop bag. And if you don't provide enough details don't be surprised someone has a different idea that you, especially with COVID when most of the treatments for the first year or two were not effective and the details you gave did not make it 100% obvious you were right. 

Otherwise we are no better than the article on CNN making assumptions about PA/NPs in the ED and there example was a lady that went to the ED 3x for bleeding during pregnancy and eventually had a spontaneous abortion and made the assumption that a ER physician could of magically done something different to avoid this undoubtedly inevitable outcome. 

Also should we even really be talking crap about our colleagues? As a nocturnist PA (who is also going to medical school). I have cleaned up crap from ER, ICU, ER and hospitalist providers alike of all credentials. Granted there are cultprits who are more likely to leave me a mess. However sometimes its better to just focus on the fact that everyone is overwhelmed, overworked, underpaid and under appreciated and in order to make it through the day have  to cut corners on occasion. And its easy to get a chip on your shoulder when you get ripped into for a mistake you make, but fix a larger mistake that goes unnoticed because someone has a certain credential. But at the end of the day we need each other and there is going to be more variability in PAs/NPs compared to MD/DOs and that's why we need 1 year required fellowships for all new PA/NPs to best assure we are meeting the standards of care and optimizing the impact they make on patients.  Also decreasing burnout and workload would help as well as like I said most of the mistakes I make is because I'm being asked to do the work of 2 or 3 providers and something falls through the cracks. 

I agree with some of what you say

 

But - I believe we all have a responsibility to protect society.  I don't think we have ever before seen a single profession (NP) make such rapid advances while at the same time they have sig watered down the quality of their education programs.  When I became a PA some two decades ago it was commonplace to interchange PA and NP as pretty much all of them were rock solid. I can not say the same anymore..... and somewhere this has to be called out.  Sure we can wait for the data to come out in 5-10 years - but there is nothing wrong with bringing it up on this board.

 

I go back to my initial post - covid + with comorbid conditions does not mean punt 3 days away.  Never has and hopefully never will......   it was clinically wrong management.  

 

I will admit I am growing tired of the corporate side of medicine that treats everyone as interchangeable (MD/DO/PA/NP) and find it especially concerning as the swiss cheese theory is real and the holes are going to line up a lot more often and 'never ever' events are going to happen more often.   I think every provider out there has a duty to be aware of what the "Team" is doing and if someone is failing uphold reasonable care then they should be given the opportunity to know this and improve.

 

 

 

just to provide framing - this was my original post

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.  

[sas5814]

One of my mantras, and I have hammered it into every student I ever had, is you better know what you don't know.  That is wayyyyy more important than what you do know.

[NEQuadrant]

On 2/13/2023 at 9:46 AM, LT_Oneal_PAC said:

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. 

I would like to echo this sentiment, but for different reasons.

This "paper" has been an NBER working paper since October of 2022. A working paper is NOT peer reviewed. The fact that AMA is using non-peer reviewed papers as evidence supporting their very public claims does suggest that this is political fodder. I guess evidence-based really just means the equivalent of a blog post written by an MD or DO.

[CAAdmission]

10 hours ago, NEQuadrant said:

I guess evidence-based really just means the equivalent of a blog post written by an MD or DO.

In the grand scheme of things, it wasn't all that long ago that the AMA was crapping on DOs. 

It's what they do. They are not interested in anything beyond turf protection.