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Brom Dissertation Final 4.10.17.pdf (1.32 MB)

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The Changing Landscape of Ambulatory Care: Provision and Utilization as Influenced by the Patient Protection and Affordable Care Act

Brom, Heather
http://orcid.org/0000-0002-4295-6372
http://rave.ohiolink.edu/etdc/view?acc_num=osu1491814890562107

Abstract Details

2017, Doctor of Philosophy, Ohio State University, Nursing.
Background and Aims: Nurse practitioners (NPs) represent a growing healthcare provider workforce, which is poised to assist with the shortages of physicians and growing demand for healthcare services driven by the Affordable Care Act (ACA). Restrictions to NP scope of practice may present a barrier to meeting this need. This research sought to determine if NP scope of practice laws were altered in response to passage of the ACA and to examine changes in the number of NPs, to test for differences in the delivery of ambulatory care in the United States, and to characterize ambulatory practice by state-level NP scope of practice post-ACA passage. Methods: This research was a mixed-methods retrospective study. State level data on NP scope of practice legislation was created using annual legislative reports and analysis guided by regulatory theory. The Area Health Resource File was used to calculate annual NP counts per 100,000 population by state from 2010 to 2014. The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS) were combined and weights applied to make national estimates of ambulatory care from 2007 to 2012. The 2012 NAMCS was the first time state-level estimates could be made with this data. Statistical analyses included descriptive statistics and differences between categorical (chi-square) and continuous (t-test) variables were calculated. A regression model was fit to determine predictors of NP counts. Results: From 2010 to 2014 seven states passed full practice authority legislation, an over three-fold increase in adoption of this legislation compared to the previous 10 years. All seven states chose to adopt Medicaid expansion and five of the states mentioned the ACA or issues with access to care. The numbers of NPs per 100,000 population increased over time (2010-2014) but broadening of scope of practice was not a predictor of NP count. The most acceleration in NP counts occurred in Southern states, which were reduced in scope. With regards to ambulatory care, from 2007 to 2012 there was an overall increase of new patients seen, but no significant change in the mix of providers (advanced practice registered nurses (APRNs), physicians or physician assistants). The provision of health education did not change for APRNs during the study period. There was a significant decrease in the provision of health education by physicians. In 2012 there were significantly more APRN visits in states with reduced scope of practice compared to full practice. Given the lack of representation of the full practice authority states in the 2012 NAMCS, estimates of APRN ambulatory care provision by scope of practice could not reliably be made. Conclusions: Healthcare reform was a driver of legislative change for states that passed full practice authority legislation but broadening scope of practice between 2010 and 2014 was not a predictor of NP count. Ambulatory care remained relatively stable during the first 2 years of ACA implementation with the number of new patient visits significantly increasing. As more recent years of NAMCS and NHAMCS data are released this will be an important analysis to re-visit as changes in demand due to the individual mandate and Medicaid expansion did not go into effect until 2014. Evaluating state-level ambulatory care highlighted a gap in using the NAMCS to make estimates of the provision of care provided by NPs. This dissertation represents a combination of data sources to provide a comprehensive and multi-view examination of NPs in terms of numbers and ambulatory care they were providing in the setting of ACA passage and early implementation.
Pamela Salsberry (Advisor)
Margaret Graham (Committee Member)
Sandra Tanenbaum (Committee Member)
162 p.
Health Care; Nursing
nurse practitioners, scope of practice, ambulatory utilization, healthcare access, primary care

Recommended Citations

Citations

  • Brom, H. (2017). The Changing Landscape of Ambulatory Care: Provision and Utilization as Influenced by the Patient Protection and Affordable Care Act [Doctoral dissertation, Ohio State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=osu1491814890562107

    APA Style (7th edition)

  • Brom, Heather. The Changing Landscape of Ambulatory Care: Provision and Utilization as Influenced by the Patient Protection and Affordable Care Act . 2017. Ohio State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=osu1491814890562107.

    MLA Style (8th edition)

  • Brom, Heather. "The Changing Landscape of Ambulatory Care: Provision and Utilization as Influenced by the Patient Protection and Affordable Care Act ." Doctoral dissertation, Ohio State University, 2017. http://rave.ohiolink.edu/etdc/view?acc_num=osu1491814890562107

    Chicago Manual of Style (17th edition)

osu1491814890562107
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