Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4073 — Quality Improvement Effort to Reduce Inappropriate Inhaled Corticosteroids: Baseline Perspectives of Nurse Practitioners and Physicians

Lead/Presenter: Seppo Rinne, COIN - Bedford/Boston
All Authors: Rinne ST (COIN - Bedford/Boston) Lea C (COIN - Seattle/Denver) Udris E (COIN - Seattle/Denver) Majerczyk B (COIN - Seattle/Denver) Rise P (COIN - Seattle/Denver) Feemster LC (COIN - Seattle/Denver) Wiener RS (COIN - Bedford/Boston) Au DH (COIN - Seattle/Denver) Helfrich CD (COIN - Seattle/Denver)

Objectives:
Advanced practice providers, such as nurse practitioners (NPs), are increasingly providing primary care for veterans with chronic obstructive pulmonary disease (COPD) though little is known about differences in clinical practice perspectives between NPs and physicians. As part of a quality improvement effort to reduce inappropriate use of inhaled corticosteroids (ICS) we explored differences between NPs and physicians in their approach to ICS use. Given the need for organizational support to deimplement inappropriate ICS use, we also examined perspectives on workplace climate and morale.

Methods:
We fielded electronic surveys in 2016 and 2017 to primary care providers at 13 primary care clinics affiliated with two VAMCs. We used Chi-squared tests to determine whether NPs differed from physicians in knowledge and intentions related to prescription of ICS for patients with mild-to-moderate COPD as well as on assessments of workplace climate and morale.

Results:
Among 134 eligible providers surveyed, 46 completed surveys (34% response rate), including 13 NPs. NPs were no different than physicians in self-reported prescribing of an ICS, awareness of guidelines, and awareness of adverse effects of ICS. They were also no different in the proportion reporting they were unlikely to change a prescription made by another provider. NPs were significantly less likely than physicians to report that their clinic leadership promotes team building to solve clinical care problems (8% vs. 52%); establishes clear goals for patient care processes and outcomes (15% vs. 52%); or encourages and supports changes in practice patterns to improve patient care (15% vs. 55%). Nurse practitioners were significantly more likely than physicians to report they would leave their current position if they could (54% vs. 9%).

Implications:
While NPs did not differ from physicians in responses regarding guideline knowledge for ICS use in COPD and self-reported prescribing behaviors related to ICS, their rating of organizational support for quality improvement was significantly lower, and their desire to leave the practice was significantly higher.

Impacts:
In our study, NPs did not differ from physicians in their approach to ICS prescribing for COPD. However, large differences in workplace climate and morale raise concerns about employee satisfaction and retention of primary care NPs.