Provider-type and Heart Failure Hospitalizations - ScholarWorks

Provider-type and Heart Failure Hospitalizations

A Research Grant Proposal

Presented to the faculty of the School of Nursing

California State University, San Marcos

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

in

Nursing

Family Nurse Practitioner

by

Maria Cecilia C. Jamito

SPRING 2017

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Abstract

of


by

Maria Cecilia C. Jamito

This grant proposal seeks funding for the collection of data that may provide a groundwork of information as to differences in outpatient care of heart failure patient by the physician vs. nurse practitioner. Results of previous research in primary care settings have shown that as compared to physicians, nurse practitioners have provided the same quality care, if not better, to patients and have effectively prevented unnecessary hospitalizations.

Physicians and nurse practitioners come from differing educational backgrounds, with the first going through four years of medical school and another four years of residency and potentially a fellowship, with the latter obtaining experience as a registered nurse and a bachelor’s degree prior to completing two to three years of graduate school. With the need for nurse practitioners steadily increasing as the baby boomer population ages, there is a need for research in the work and care given by nurse practitioners, with comparisons to the traditional providers—physicians.

The study will look to see if a model nationwide healthcare organization that places physicians and NPs on an almost equal playing field in outpatient care will show if NPs provide the same if not better, outpatient heart failure management.

Statement of Problem

Heart failure is just one chronic disease managed by physicians and nurse practitioners, and if managed poorly, results in exacerbations and recurrent hospitalizations which require the administration of intravenous diuretics and closer monitoring of the patient. This in turn, results in a decreased quality of life for the patient, as well as a burden of costs on the patient and nation as a whole. Exacerbations of heart failure are widely considered to be preventable, so a closer look may give some insight as to the efficacy of heart failure management relative to a particular provider-type.

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ACKNOWLEDGEMENTS

Thank you to my supportive friends and family for helping me through the turbulent ups and downs I experienced in my three years of grad school. I can’t imagine having gotten as far as I have without you

all by my side. Special thanks to Dr. Denise Boren, Dr. Linnea Axman, and Lindsey Sheets for your guidance, and my mom Lyn, dad Jun, sister Marie, and boyfriend Francisco for all of your love!

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Running head: PROVIDER-TYPE AND HEART FAILURE HOSPITALIZATIONS

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Chapter One: Introduction Background and Significance

Heart failure is a “complex clinical syndrome” that results from an abnormal structure or

dysfunction of either the filling of the ventricles with blood or the ejection of the blood (Yancy et

al., 2013). Shortness of breath (dyspnea) and fatigue are the main clinical manifestations of heart

failure which limit one’s tolerance for exercise, and the retention of fluid, which can potentially

lead to congestion in the lungs and organs in the abdomen or thorax (Yancy et al., 2013)

Heart failure is a preventable disease – patients have the ability to control their blood

pressure, diet, and other vascular risk factors (Delgado-Passler & McCaffrey, 2006). Patients

frequently need to be hospitalized when heart failure is exacerbated, but hospitalization is also

considered largely preventable (Delgado-Passler & McCaffrey, 2006).

Unplanned hospital admissions place a tremendous strain on healthcare systems

throughout the world, and have costly repercussions (Busby, Purdy, & Hollingworth, 2015).

This budget issue is ever-increasing, with a 13% increase in hospital bed days in the USA

between 2000 and 2009 (Busby et al., 2009). Unfortunately, and perhaps more grave, are the

serious health implications of the need for increased unplanned hospital admissions. The

increases may be a result of a mixture of the following: patient populations growing more

acutely ill, suboptimal primary care prevention and follow-up, non-compliance, and/or

inadequate care during the hospital stay.

Three critical factors of heart failure care include patient and family education, support,

and involvement (Yancy et al., 2013, p. e295). Per the American Heart Association (Yancy et

al., 2013, p. e295), a likely cause of the United States’ high rates of re-hospitalization and

PROVIDER-TYPE AND HEART FAILURE HOSPITALIZATIONS

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mortality in heart failure patients within 30 days is the “failure to understand and follow a

detailed and often nuanced plan of care.”

Heart failure is associated with a decreased health-related quality of life. Heart failure

“significantly decreases health-related quality of life, especially in the areas of physical

functioning and vitality” (Yancy et al., 2013). Lack of a post-hospital discharge improvement in

health-related quality of life is a strong predictor of a patient’s readmission to the hospital and

mortality (Yancy et al., 2013). Additionally, heart failure risk factors and subsequent

concomitant conditions such as diabetes mellitus, metabolic syndrome (consisting of abdominal

adiposity, hyperlipidemia, hypertension, and fasting hyperglycemia), and atherosclerotic diseases

further decrease heart failure patients’ health-related quality of life (Yancy et al., 2013). Hence,

it is imperative that primary care providers make the effort to educate and improve patient

outcomes during clinic encounters.

Heart failure has a staggering financial burden. In the United States, the numbers of

unplanned hospital admissions (and subsequent readmissions) for heart failure and heart failure

exacerbation are astounding. Heart failure is the primary diagnosis in over 1 million

hospitalizations every year, with patients at a high risk for all-cause re-hospitalization, and a

readmission rate of 25% within one month (Yancy et al., 2013, p. e248). Additionally, over half

of the $30 billion+ spent annually on heart failure in the United States is spent on

hospitalizations (Yancy et al., 2013, p. e248). Since 2012, the Centers for Medicare & Medicaid

Services have “reduced payments to inpatient prospective payment system hospitals with excess

readmissions” (David, Britting, & Dalton, 2015). Therefore, it is prudent and imperative that

care should be taken to decrease hospital admissions and readmissions in the heart failure

population.


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The Problem

Per Yancy et al. (2013), one in five Americans will be older than 65 years of age by the

year 2050. Because the prevalence of heart failure is highest in those 65 years of age and older,

“the number of Americans with heart failure is expected to significantly worsen in the future”

(Yancy et al., 2013). In 2043, 6.3 million veterans are projected to be 65 years of age and older

(U.S. Department of Veterans Affairs [VA], 2015c). However, perhaps more alarming is the

steadily increasing numbers of baby boomer veterans getting older now – a whopping 9.8 million

veterans were 65 years of age and older in 2013 (VA, 2015c). Because of this, action must also

be taken now to improve both the health-related quality of life for this sample of patients, while

also lessen the financial burden of the disease.

Purpose of the Research

The purpose of this study is to determine if outpatient heart failure care provider-type

(physician or NP) has an impact on numbers of heart failure exacerbation

admissions/readmissions.

Implications for Nursing Practice/Policy/Research

Among those caring for heart failure patients are physicians (MDs/DOs) and mid-level

providers, which include nurse practitioners (NPs) and physician assistants (PAs). Worldwide,

substitution of physicians by nurse practitioners in primary care has become commonplace as a

result of physician shortages “and the need for high-quality, affordable care, especially for

chronic and multi-morbid patients” (Martínez-González et al., 2014). However, despite the

national shortage of primary care physicians, disagreement exists as to NPs role in the leadership

of clinical practice (Buerhaus, DesRoches, Dittus, & Donelan, 2015). Therefore, it is important

to examine the impact that nurse practitioners have in outpatient care.


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Research Question

In adult patients receiving heart failure care at a major military medical center in southern

California, is there a difference in the number of hospitalizations for heart failure exacerbation

based on provider-type?

Hypothesis

Although physician and NP education and training differ, NPs will either have the same

numbers or lower rates of patients with heart failure exacerbation admissions. This will be

attributed to the different approach that NPs take in caring for their patients through Lydia Hall’s

Care, Cure, Core Theory.

Research Variables

The dependent variable in the study is the unplanned hospital admission related to heart

failure exacerbations. The independent variables studied were outpatient care provided by

physicians and outpatient care provided by nurse practitioners.

Conceptual Model

Lydia Hall’s Care, Cure, and Core Theory. The theory shows the importance of nursing

interventions – in this case, advance practice nursing, on the care of heart failure patients.

Assumptions of Hall’s Care, Cure, and Core Theory (Wayne, 2014):

1. The motivation and energy necessary for healing exist within the patient, rather

than in the healthcare team.

2. The three aspects of nursing should not be viewed as functioning independently

but as interrelated.

3. The three aspects interact, and the circles representing them change size,

depending on the patient’s total course of progress.


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Importance of the Research

Research is needed that will examine the impact of NP care on patient and utilization

outcomes (David et al., 2015), especially with heart failure exacerbation admission and

readmissions. An association between primary care provider type and unplanned hospital

admissions for heart failure exacerbation can aid in supporting potential initiatives that either

improve access/quality to primary care, or develop alternatives to hospital admissions (Busby et

al., 2015). Decreased hospital admissions means decreased costs, and would demonstrate

improved control of patients’ heart failure.

An unplanned hospitalization for heart failure exacerbation is costly for both patients’

health and hospitals’ budgets. A closer look at patients’ primary care provider-type may aid in

determining what, if anything, a certain provider-type may be doing that leads to less

hospitalizations. Because many admissions for conditions cared for and addressed in

ambulatory/primary care are preventable (Busby et al., 2015), it is important to look at the

practice characteristics of primary care providers, and see what best-practice is in treatment and

maintenance of heart failure. The Veterans Health Administration (VHA), an organization of the

VA, is a prime health care system to study due to its relatively expansive use of NPs,

“unparalleled national system of coded data,” and “the high burden of chronic disease in its

population” (Morgan, Abbott, McNeil, & Fisher, 2012). NPs employed by the U.S. Department

of the Navy are also ideal to study, as they are considered to be “licensed independent

practitioners that function in an expanded and specialized area of nursing and possess the

knowledge and clinical skills required to accept and provide services to patients requiring

primary care management” (“BUMEDINST 6550.10B,” 2015).


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Chapter Two: Literature Review

Introduction

Research articles were identified through PubMed, Cumuluative Index to Nursing and

Allied Health Literature (CINAHL), SAGE Journals, the Cochrane Database of Systematic

Reviews, and ScienceDirect databases. Literature search terms included “primary care,”

“unplanned hospital admissions,” “heart failure exacerbation,” and “ambulatory care.” The

search was limited to English language, peer-reviewed articles with full-text available.

Previous research exists on heart failure admission rates and the acute care nurse

practitioner (David et al., 2015), but research is lacking with respect to care of these patients by

primary care NPs. Even withstanding, David et al.’s (2015) research on the cardiac acute care

nurse practitioner’s role in decreasing 30-day readmissions is a step in the right direction. In a

retrospective 2-group comparative study, David et al. (2015) evaluated the outcomes of 185

cardiovascular intensive care patients with either ST- or non-ST-segment elevation myocardial

infarction or heart failure in an urban medical center. The patients were either treated by a

medical team and cardiac acute care NP (n = 109) or the medical team alone (consisting of only

physicians) (n = 76). The findings of the study were impressive:

• Those who received care from a medical team with a NP were readmitted

approximately 50% less often than those who received care from a medical team

without a NP

• 30-day hospital readmission (p = .11) and 30-day return rates to the emergency

department (p = .21) were both significantly lower in treatment teams that

included a NP.


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“The [VHA] has been a frontrunner in the use of [NPs and PAs],” with the two

professions providing approximately 30% of all primary care encounters (Morgan et al., 2012).

The VHA is the U.S.’s largest integrated health system and “is a leader in primary care

innovation” (Morgan et al., 2012). As will be described further in the “Major Variables

Defined” section, both VHA primary care NPs and Department of the Navy NPs (civilian or

military) function similarly to physicians. The prominence of NPs in the VHA and in Navy

Medicine brings about a need for an analysis as to the impact of NP care of both patient and

utilization outcomes (e.g., decreased heart failure exacerbation admissions and readmissions).

A systematic review by Laurant et al. (2005), through The Cochrane Collaboration,

gleaned 4253 potentially relevant studies, and reduced the review to 16 relevant studies that met

inclusion criteria regarding the substitution of physicians by nurses in the primary care setting.

The studies suggested that with appropriate training, nurses in primary care can provide care as

high of a quality as primary care doctors and their patients can achieve equally optimal health

outcomes.

Though a systematic review of 24 randomized clinical trials (RCTs) by Martínez-

González et al. (2014), analysis “showed that NPs had a positive effect in reducing all-cause

admissions to [the] hospital (RRs 0.74, 95% CI 0.62 to 0.89),” estimates increased with non-

urgent, on-going care (primary care) visits with lengthened follow-up episodes of at least 12

months and in large RCTs (N>200).

Mundinger et al. (2000) conducted a randomized clinical trial of 1316 patients with no

regular source of care, with random enrollment and initial primary care appointments with either

a NP (n = 806) or physician (n = 510). The setting for the study occurred at four community-

based primary care clinics with 17 physicians and one primary care clinic with seven nurse


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practitioners at an urban, academic medical center (Mundinger et al., 2000). The aim of the

study was compare outcomes for these patients in a setting where nurse practitioners and

physicians practiced with the same degree of independence. The results of the study generally

showed support for NP care:

• Patients’ health status: no significant differences at six months (p = .92)

• Physiologic test results for diabetics or asthmatics: no significant differences (p =

.82, p = .77, respectively)

• Diastolic blood pressure in hypertensive patients: Statistically significantly lower

for NP patients (82 vs. 85 mmHg; p = .04)

• Health services utilization after six months or one year: no significant differences

• Satisfaction ratings after initial appointment: no differences (p = .88 for overall

satisfaction)

Major Variables Defined

Physician. Physicians are also known as doctors of medicine [MDs] or doctors of

osteopathy [DOs]) and have little-to-no restrictions on medical practice. They diagnose and treat

illnesses and injuries (Bureau of Labor Statistics [BLS], 2014b). Their medical training is a

rigorous and a long drawn-out process. They complete four years of medical school after

obtaining a bachelor’s degree, receive either a doctoral or professional degree upon graduation.

After graduation, they are matched into an internship, residency, or fellowship for three to eight

years of on-the-job training before being able to fully practice independently as an attending

physician.

Title 38 United States Code (U.S.C., also called the Code of Laws of the U.S.A.)

mandates that the VA is required to assist in training resident physicians, as well as other health


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professional trainees, to optimize the quality of care provided to Veterans under the VA health

care system (VA, 2015b). In 2014 alone, the VA’s Graduate Medical Education (GME) program

consisted of 41,223 medical residents, 22,931 medical students, and 311 fellows – all of which

received their clinical training at a VA facility (VA, 2015b). Additionally, 135 of 141 allopathic-

accredited (also known as “western medicine,” which MDs fall under) medical schools and 30

out of 40 osteopathic medical schools (which ODs fall under) have affiliation agreements with

the VA (VA, 2015b). Because the VHA is a teaching organization that relies heavily upon

resident physicians that continuously rotate through primary care (among other specialties), they

will be considered physicians in the study.

Through their GME program, a southern California Naval Medical Center has also

provided physicians opportunities for internships, residencies, and fellowships for the past 70

years and trains these physicians to provide care for active and prior military patients and their

families (“GME – Internal Medicine Residency,” 2017). In the prospective study, care provided

by physicians, whether they be interns, residents, or attendings in a primary care setting that

precedes an admission for heart failure exacerbation will be included, and will be one of the two

independent variables.

Nurse practitioner. Nurse practitioners are registered nurses (RN) with graduate- or

doctoral-level training. The minimum degree required of nurse practitioners is a master’s

degree, which is a two- to three-year long program post-bachelor’s degree (BLS, 2014a). A

residency is not required to practice, and is uncommon. In the United States, each state has its

own jurisdiction over their nurse practitioners’ scope of practice – some states are more or less

restrictive than others. In states where their licensure and scope of practice is restricted, nurse

practitioners are considered mid-level practitioners, outranked by physicians. VHA primary care


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NPs function more as substitutes for physicians, rather than as complements (Morgan et al.,

2012). VHA primary care NPs are typically responsible for managing their own patients, can

prescribe medications, place orders, and can sign documentation without physician co-signatures

(Morgan et al., 2012). As stated earlier, the Department of the Navy employs NPs that act as

independent providers in primary care, whose clinical judgment are theirs alone, without

supervision by a physician (“BUMEDINST 6550.10B,” 2015). Care provided by nurse

practitioners in a primary care setting, preceding or following an admission for heart failure

exacerbation will be included in the study, and will be the other of the two independent variables.

Primary care. The American Academy of Family Physicians (AAFP), the national

association of family physicians, provided definitions of primary care and their own descriptions

of those who provide primary care. Per the AAFP (2015), primary care is care provided by those

with specific training and skills in comprehensive initial visits, as well as ongoing care for

anyone with undiagnosed signs, symptoms, or health concerns. The AAFP’s stance on providing

primary care is that non-physician primary care providers “may meet the needs of specific

patients,” and they should only practice collaboratively with physicians, who retain the “ultimate

responsibility” of the patient (AAFP, 2015). Beliefs such as this are another justification for the

need for this study. The organization is against allowing NPs to take the reins in caring for

primary care patients, and insists on maintaining a hierarchy of providers. Research must be

conducted in an effort to provide evidence-based support for the role of the nurse practitioner.

Heart failure. The World Health Organization has assigned the diagnosis of heart

failure the code I50 under the current version of International Classification of Diseases, version

10-Clinical Modification (ICD-10-CM; Centers for Medicare & Medicaid Services [CMS],

n.d.b) and 428 under the previous version, ICD-9-CM (CMS, n.d.a). This standardized code is


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used internationally to refer to heart failure. Only patients with an I50 code on their problem

lists will be included in the study. The number of heart failure exacerbation hospital admissions

for a particular patient will be tallied and categorized under either care from primary care NPs or

primary care physicians.

Veteran. There are numerous criteria for what qualifies someone as a Veteran that can

receive VA or military healthcare, but for simplicity’s sake, a veteran is someone who served in

the U.S. military. Male veterans are much more prevalent than female veterans; the VA (2015c)

reported that in 2013 there were 20.2 million men in the total of 22.2 million living U.S.

veterans. (This means that women made up only 2.2 million of the veteran population.).

There may be a link between veterans, post-traumatic stress disorder, and heart disease –

making this population all the more important to study. In a study of 281 pairs of twins who

served in the military during the Vietnam War, those who were diagnosed with PTSD were more

than twice as likely to develop heart disease than those that did not (23% vs. 9%) (Kuehn, 2013).

Theoretical Framework/Conceptual Model

According to nursing theorist Lydia Hall, the patient consists of three aspects: the person,

the body, and the disease (Parker & Smith, 2010). Per Hall, medicine (e.g., physicians) is

responsible for pathology and treatment, but the area of person is “sadly neglected” (Parker &

Smith, 2010). An expert nurse “must know how to modify the care depending on the pathology

and treatment while considering the patient’s unique needs and personality” (Parker & Smith,

2010). Hall’s Care, Cure, and Core Model stands to represent the nature of nursing, with three

overlapping circles that change in size according to a patient’s phase of healing (Parker & Smith,

2010).


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Care. Hall suggested that providing intimate bodily care to patients (i.e., activities of

daily living such as bathing, feeding, toileting, etc.) is an aspect that belongs entirely to nursing

(Parker & Smith, 2010). This is just one example of “care;” building rapport through an

interpersonal relationship is perhaps a more overarching use of the term. The model holds that

the patient as a person (in addition to his/her body) will respond to the physical/comforting care

provided by the nurse. The care circle is predominant during the evaluation and follow-up phase

– where primary care nurse practitioners carry out their therapeutic interventions and teaching.

Cure. This is the area of the nursing process that is shared with physicians (medicine).

Interventions of a medical/surgical nature that are performed by nurses fall under this circle.

These can include tasks such as measuring intake and output as a bedside nurse, to diagnosing

and prescribing medications as a nurse practitioner. This portion of the circle is largest during

the acute care phase, or when patients are hospitalized for heart failure exacerbations.

Core. This area of nursing is shared with other helping professions, and emphasizes the

“social, emotional, spiritual, and intellectual needs of the patient in relation to family, institution,

community, and the world” (Parker & Smith, 2010). The core is based on the therapeutic use of

oneself and the social sciences (Parker & Smith, 2010). With the aid of nurses’ comfort and the

provision of intimate bodily care, the patient will comfortably be able to introspectively explore

the core of his or her being. Questions answered that will rapidly progress one towards healing

and rehabilitation include who a person is, where that person is and where they want to go, and

whether or not they will accept help in getting there (Parker & Smith, 2010). All-in-all, this

framework can be an explanation for the high quality of care provided by NPs, despite having a

shorter education and less training compared to physicians.


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Summary. Using Lydia Hall’s Care, Cure, and Core Model, the professional nurse (and

nurse practitioner) provides care that assists the patient in learning to reach the core of his or her

difficulties, and sees him or her through the cure (Parker & Smith, 2010). Through this nursing

process, the patient has the potential to learn from his or her illness, and may even emerge

healthier than they were prior (Parker & Smith, 2010). Despite the differences in schooling and

training, nurse practitioners’ unknowing application of the nursing process as described Lydia

Hall’s Care, Cure, and Core Model helps to bring their quality of care up to par with that of

physicians’.


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Chapter Three: Methodology

Introduction

With the high rates of heart failure in the U.S., and the shift towards increased utilization

of NPs in primary care, it is pertinent that research be conducted on the impact that NPs have on

patient outcomes and quality of life. This is especially true because of the known lower health-

related quality of life associated with repeated hospital admissions for heart failure exacerbation.

Differences in training and education may or may not be a factor in numbers of admissions, and

this study aims to find out just that. If the research shows that NP care results in either the same

outcomes as physicians, or perhaps even more so if NP care results in less admissions, further

evidence in support of the role of the NP will be added to the body of knowledge. With more

evidence is the potential for changes in either state policy on NP scope of practice, and also

providing funding for hiring more NPs nationwide.

Research Question

In adult patients receiving heart failure care at a major military medical center in southern

California, is there a difference in the number of hospitalizations for heart failure exacerbation

based on provider-type?

Hypothesis. Although physician and NP education and training differ, primary care NPs

will either have the same numbers or lower rates of patients with heart failure exacerbation

admissions. This will be attributed to the different approach that NPs take in caring for their

patients through Lydia Hall’s Care, Cure, Core Theory.

Null hypothesis (H0). There will not be a difference in the number of heart failure

exacerbation admissions after care from either a primary care physician or primary care NP.


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Alternative hypothesis (HA). There will be a statistically significant difference in the

number of heart failure exacerbation admissions after care from either a primary care physician

or primary care NP.

Identification of Setting

Because the same patients commonly seek care in both the VA system and in military

hospitals, where NPs practice primary care independent of a physician, an argument can be made

for the setting of the research study to be in either healthcare system. The VHA might have

ample data, as it is “the United States’ largest integrated health care system consisting of 150

medical centers, [and] nearly 1,400 community-based outpatient clinics (CBOCs)” (VA, 2015a).

Although the VHA is at first glance an obvious choice due to the entire patient population

consisting of veterans, the researcher will opt for studying heart failure patients at a southern

California military hospital instead. (The reason for this will be explained further in the “Chapter

Four: Grants Elements” section.) This study will not be inclusive of all nationwide military

facilities, as it would require extensive time and research, although it could provide valuable

information for a future study. Southern California is an ideal location to study patients, due to

the concentration of numerous military bases in the region, and its diverse patient population.

Additionally, the hospital’s mission is aligned with that of the researcher’s: to “[provide] the

safest, highest quality patient-centered medical care for [the] veterans” (Naval Medical Center

San Diego [NMCSD], 2016). The medical center reports having received more than 1.2 million

outpatient visits and having admitted more than 19,000 patients in 2014 alone (Naval Medical

Center San Diego, 2016).


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Research Design

A non-experimental, retrospective longitudinal study will be completed on outpatient

care encounter data from a major military hospital in southern California. A follow-up study as a

type of longitudinal design is preferred, because clinical data will be collected at more than one

point in time over an extended period on the same patients (Polit & Beck, 2012, p. 187). A

limitation of archival research is that patients may have been admitted to civilian hospitals for

heart failure exacerbation, and this is likely not recorded in the military electronic chart. Another

limitation of the design in that looking backwards in time in a patient’s chart may very likely

show changes in provider type throughout the continuum of care.

Population and Sample

A moderate effect size of 0.30 will be used, as there is a lack of previous research on this

particular topic. The significance level will be .05, with a power of 0.80. After inputting the

aforementioned values into the computer software G*Power 3.1, a total sample size of 352

(n=352) was determined, with 176 patients in each group (Faul, Erdfelder, Lang, & Buchner,

2009). The total degrees of freedom are 350 (n – 2) and the critical value for the t-statistic (which

will determine whether the null hypothesis will be rejected) is 1.960. Attrition will not be

accounted for, as the data will be obtained from retrospective chart reviews, and will be collected

via quota sampling. Quota sampling is a semi-purposive sampling method (Polit & Beck, 2012,

p. 279). Data collection will conclude once data on 176 patients who meet criteria for both

groups are collected. A confidence interval will be set at 95%, because per Polit & Beck (2012),

it is richer and more powerful in clinical application than p values alone.

Demographic variables include physicians, nurse practitioners, and veteran patients.

Inclusion criteria for providers include those treating patients in outpatient with a title of MD,


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OD, or NP. Exclusion criteria for providers are any physician assistants, as they are neither

physicians nor nurse practitioners. Inclusion criteria for the patients include those with ICD-9-

CM and ICD-10-CM codes for heart failure, those receiving outpatient heart failure care from

either an NP, MD/OD at a major military center in southern California, and those that have had

at least one heart failure exacerbation hospital admission. Exclusion criteria for patients include

heart failure patients with no prior heart failure exacerbation admissions.

Measurement Methods

A tool will be made in the form of a Microsoft Excel worksheet that will list the number

of individual patients’ hospitalizations for heart failure exacerbation and will include their

outpatient care provider type. This data will then be transferred to SPSS 22, a statistical analysis

software. The independent variables of physician care and NP care are considered to have a

nominal level of measurement, while the dependent variable of numbers of heart failure

exacerbation admissions (per patient) are a ratio level of measurement.

In the study, the number of hospitalizations a patient has will be operationalized by

merely counting the number of heart failure exacerbation admissions a patient has. NP care and

physician care will be operationalized by looking at signed provider notes and looking at those

providers’ credentials/titles.

Data Collection Process

Chart reviews of the patients’ electronic health records will provide the data necessary for

this study. As stated before, data will be collected retrospectively, and will follow individual

patients’ records from their first heart failure exacerbation to their most recent. In order to

collect the most recent and relevant information, quota sampling will occur in a reverse

chronological order – meaning that data will be collected starting at the current time and going


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backwards. Data will be kept on an Excel document that will be saved on a password-protected

laptop. Because the data will contain personally identifiable information, and is needed to

backtrack and verify the researchers’ work prior to finalization of reports, care will be taken so

that the information is deleted as soon as analysis is complete. Additionally, patients’

confidentiality will be protected by ensuring that personally identifiable information is not

accessible to anyone outside of the research team, and that the team is trained on the Health

Insurance Portability and Accountability Act of 1996 (HIPAA), a federal law protecting patient

information.

Coding

Numeric codes have been assigned to represent the grouping variables (1 = outpatient

care from physicians and 2 = outpatient care from NPs). These codes will be used in both Excel

and SPSS. Scoring not does apply to this study and therefore will be omitted.

Data Analysis

A two-tailed independent t test will be performed, in order to compare the means of the

grouping/independent variables (outpatient care of heart failure patients by physicians vs. NPs),

and to detect any differences between the two (Kellar & Kelvin, 2013, p. 98). The data will meet

all of the necessary assumptions, due to the following:

1. The grouping variable is dichotomous (care by physicians and care by NPs)

2. The data points (each heart failure exacerbation hospitalization) are independent

of one another.

3. Data are normally distributed.

4. The number of hospital admissions is a ratio variable.


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Bias

Selective deposit and selective survival are two biases that will be considered when

controlling for threats to internal validity. Selective deposit can result when patients’ health

records or documents are not the complete set of record, but are instead selectively retained

based on criteria that could potentially bias the complete set (Polit & Beck, 2012, p. 742).

Selective survival is a bias that may occur when selected patients’ records are not a complete set

of records because of a non-random method of maintaining them (Polit & Beck, 2012, p. 742).

For this study, data will be selectively handpicked from nationwide military electronic health

records based on inclusion criteria. In an attempt to curb selection bias while also attempting to

collect the most recent or relevant data (especially with regards to provider-care), patients will be

selected by going backwards in time, and stop upon fulfillment of the quota/sample size (176

patients who received primary care from a physician, and 176 patients who received primary

care from a nurse practitioner).

Ethical Considerations

Ethical issues for consideration are relevant to the sample of patients. Veterans are a

potentially vulnerable population because of the following (deLanda, 2010):

1) Their history of obeying orders from their superiors & making sacrifices for the

benefit of others

2) The disparities in their access to other health care – some may not have access

due to their socioeconomic status

3) Active duty may have contributed to psychological issues (e.g. posttraumatic

stress disorder [PTSD])


20

Therefore, careful, intentional and conscientious protection of these patients’ health information

will be protected at all times. As described earlier, they will be safeguarded through the research

design. Only data that exists as a result of standard care will be included – there is no

intervention in the form of an experiment and only prior data will be collected. The researchers

will use patient identifiers such as full name and birthday to access the record, but these details

will be deleted prior to removal of data collection sheets from the clinic site. Permission will be

requested and received to remotely access patient records, and research will be completed on a

password-protected computer.

Summary

As discussed earlier, active duty may have contributed to psychological issues such as

PTSD. Additionally, there may be a link between veterans, post-traumatic stress disorder, and

heart disease. Therefore, the cardiac health of our veteran population, and any factors

contributing to better health outcomes should be studied.

Possible limitations of the study may include patient and/or family members’

undetermined involvement and compliance/non-compliance with their care. This study will

solely be looking at provider type, and with the data collected, will attempt to identify any

differences in heart failure patient outcomes. Additionally, the study does not account for

changes in provider – the data will be collected according to who initially cared for the patient.

As discussed earlier, heart failure as a condition is a complex syndrome, with other highly likely

co-morbidities such as diabetes. This study will only be looking heart failure, and future studies

that include information on co-morbidities and patient involvement in their care can be further

stratified and assessed. Furthermore, the sample will only include veteran patients in southern

California. Lastly, most veterans in general are male (VA, 2015c), therefore data will heavily


21

consist of male patients with a poor representation of women (approximately a 10:1 ratio).

However, because gaps in the literature still show a need for any research on the impact of NPs

on heart failure exacerbation, the study will still be beneficial in the care of the heart failure

patient.


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Chapter Four: Grant Elements

Grants Considered and Chosen

Three grants were considered for funding of the proposed research: VA Research;

American Heart Association (AHA) Institutional Research Enhancement Award (AIREA); and

the TriService Nursing Research Program.

At first glance, VA Research was initially considered to be the best pick as far as where

to receive funding, as the funding would directly benefit the sample patients in the study.

However, upon further inquiry, the principal investigator (PI) would not be eligible for

application with just a master’s degree. Rather, a VA-employed doctorally-prepared nurse

clinician/scientist would have to hold the title of PI. Potentially, this doctorally-prepared nurse

could serve as PI while the applicant is relegated to assistant investigator (AI), but with the

timeline required of the study and little time to find an available VA-employed nurse

clinician/scientist with a doctorate, the author has opted instead to be the PI herself.

The AHA has provides various awards for different research purposes. Their Mentored

Clinical and Population Research Award allows funding for “all clinical and population research

broadly related to cardiovascular disease and stroke” (AHA, 2016). Their required focus appears

to be an easy fit for the purpose of this study, however the funding per year does not cover the

proposed budget and timeline. Although applications from VA employees will be accepted,

because the VA institution in itself will only allow doctorally-prepared VA nurse scientists to

serve as PIs in any VA-related project, the feasibility of this grant is additionally reduced.

Lastly, per the AHA restrictions for applying, if the research is to be performed at a military

hospital (a federal institution), the researcher’s application will face a high probability of being

rejected.


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The TriService Nursing Research Program (TSNRP) is the most ideal organization from

which to apply for a grant, as it offers an Exploratory Research Award, and would be likely to

support nurse practitioner research at the intended clinical site, a southern California military

hospital. Research priorities for the TSNRP include “description and evaluation of the military

nursing competencies necessary to sustain a patient from [a] health event through the continuum

of care” (Uniformed Services University of the Health Sciences, 2016c). The TriService

Nursing Research Group (TSNR Group)’s origins lie in the informal meetings held by

doctorally-prepared Army, Navy, and Air Force Nurses at the Association of Military Surgeons

of the U.S. convention in 1988 (Uniformed Services University of the Health Sciences, 2016a).

The TSNRP continues to promote military nursing research and the participation of doctorally-

prepared nurses in that research, as there very “few, if any, doctorally prepared nurse researchers

[that] participate as investigators in other [Department of Defense] medical research,

development, test, and evaluation programs” (Uniformed Services University of the Health

Sciences, 2016a). The TSNRP Exploratory Research award is intended for “preparatory

investigations that may lead to larger studies that follow from advancements made by this work”

and awards $150,000 per year for up to 2 years. Additionally, investigators can range from

novice to experienced, will have a mentor that is either an active, reserve, or retired nurse officer,

and allows the researcher to generate preliminary data or show feasibility of research before

applying for a larger grant award (Uniformed Services University of the Health Sciences,

2016b).


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Budget Total: $119,678

Personnel cost. Maria Jamito, MSN, RN will serve as Principal Investigator (PI) on this

research project. Ms. Jamito will receive her Master’s in Nursing with a focus on specializing as

a family nurse practitioner in May 2017. She has five years of experience as a registered nurse–

all of which have been working with veterans within the VA San Diego Healthcare System. She

will be responsible for the overall direction of the study, including presenting the study to the

Institutional Review Board, forming a research team and leading their meetings on a regular

basis, overseeing the study budget, and preparing progress reports. She will devote 50% of her

time to this project, while maintaining part-time work as a nurse practitioner. Based upon San

Diego average salaries for a nurse practitioner and principal investigators, the salary requested

for Ms. Jamito will be $48,000 plus fringe benefits of 26% ($12,480), which total $60,480 for

the year-long study (Indeed, 2016).

The two research assistants (RA’s) for this study are to be determined. The ideal

candidates are those who are bachelor-prepared, with experience in either nursing, heart failure,

or working with electronic health records. They will be responsible for (a) collection of data as

assigned by the PI, (b) verify the accuracy and validity of data entered in databases, and (c) will

provide assistance to the PI with preparation of reports, manuscripts, and presentations

(PayScale, 2016). Based on Glassdoor (2016)’s estimation of research assistants’ salaries in San

Diego, the requested salaries of each research assistant will be $12,000 with fringe benefits of

26% ($3,120), totaling to $15,120 per RA for the year-long study. They each will devote 50% of

their time to this project.

Consultant costs. Dr. Linnea Axman, DrPH, MSN, FNP-BC, FAANP, will provide

guidance and support in quantitative methodology and analysis, including but not limited to


25

computer-assisted quantitative analysis. Dr. Axman is a family nurse practitioner and professor

who recently moved to Chicago, IL, from San Diego, CA, and has a wealth of experience in

military nursing and research. She will provide 20 hours of consultation for this one-year study.

Total cost is $3000 ($150 x 20 hours).

Major equipment. Three laptop computers and a printer are needed to create reports,

and store and analyze data. USB flash drives will be needed to back up data from the laptop hard

drives. Total cost is estimated at $1325 ($400 Dell laptop x 3 laptops; $80 printer; $15 32gb

USB flash drive x 3).

Materials/supplies/consumables. General office supplies and copy paper will be

needed during the study. General office supplies include writing supplies, staplers, and printer

ink are estimated at $500 for the 1-year study. Copy paper will be needed for forms,

correspondence, and transcribed data, which includes draft/final reports. The estimated expense

for copy paper is $150 ($30/case x 5 cases). Total cost is estimated at $650.

Software. Microsoft Office and IBM SPSS 22 are software programs that will be needed

for the collection, storage, and statistical analysis of data. One subscription of Microsoft Office

365 Home can be downloaded onto up five PCs or devices, which will be enough to cover the

three laptops requested. The Office suite will be used for creation of the manuscript, any reports,

presentations, and contains the Excel software which will hold the collected data for transfer into

SPSS 22. SPSS 22 is a statistical software product for data management and analysis. The Base

version of SPSS 22 for Windows will suffice for the purposes of this research study. Total cost

is estimated at $1269.99 ($99.99 for 1-year subscription of Microsoft Office 365 Home 2016,

$1170.00 for 1-year subscription of SPSS 22).


26

Travel costs. (Average estimates for flights, hotel accommodations, and rental cars were

obtained from Expedia.com.) The PI will travel to Denver, CO to present their findings at the

American Association of Nurse Practitioners (AANP) 2018 National Conference on June 26-July

1, 2018. Total cost is estimated at $1645 ($250/night for hotel stay x 5 nights, $340/round-trip

ticket, $45/day for one rental car x 5 days).

The study consultant, Dr. Axman, will travel to San Diego, CA from Chicago, IL 2 times

during the 1-year study. The consultant will meet with the project team members to discuss

computer-assisted content analysis. Total cost is $1960 ($500 round-trip flights from Chicago to

San Diego x 2 round-trip flights; $200/night for a hotel in San Diego x 4 nights, $40 rental

car/day x 4 days).

Facilities and administrative costs. Facilities and administrative consortium/contractual

costs will be about 19%, or $19108.

Grand total. The total budget requested comes out to $119,678.


27


28


29

Timeline (12 months)

Planned actions 1 2 3 4 5 6 7 8 9 10 11 12 Obtain IRB approval Recruit & hire research assistants Obtain remote access and personal health information (PHI) access for research team members

Train research assistants Data collection Data analysis Data interpretation DRAFT final results to research assistants and consultants/advisors

Final report preparation Final report to TriService Final manuscript preparation Dissemination of findings Publication manuscript submitted to ANA/AANP

Plan for Dissemination of Findings

A final report with data, results, and recommendations for future research studies will be

given to the TriService Nursing Program, as they will have provided for the funding of the study.

Additionally, “white papers” and oral presentations to Naval Medical Center leadership and

policymakers, and a PowerPoint of the presentation of the study will be e-mailed to providers

throughout the hospital’s regional outpatient clinics.

As poignantly explained by Cynthia Saver (editor of Anatomy of Writing for Publication

for Nurses), “We [as nurses] have a responsibility to share our knowledge with each other. We

often talk about being advocates for our patients, but we also have to be advocates for ourselves.

One way to do that is to help each other enhance our ability to the deliver the best patient care

possible and to take care of ourselves as human beings” (American Nurses Association [ANA]

Career Center Staff, 2014). Keeping in mind the ANA’s (2016) mission statement “Nurses


30

advancing our profession to improve health for all,” the research team will publish a manuscript

for submission to the ANA, so that nurses without an advanced degree will be motivated to

improve upon their care of heart failure patients, and further their education for the continued

progression of the nursing practice. Additionally, a manuscript will be submitted to the AANP

for printing in their journal, for widespread distribution to nurse practitioners.

Additionally, as explained earlier in the costs section, the primary investigator plans on

presenting the study with results in the form of posters and oral presentations in national

meetings including but not limited to the AANP National Conference in late June 2018. The

AANP organization is the largest full-service national professional membership organization for

NPs of all specialties (AANP, 2016). The AANP’s mission is aligned with that of the

researcher’s – to empower nurse practitioners to advance quality care through either practice,

education, advocacy, research, and leadership (AANP, 2016). The researcher’s hope is that by

sharing the results of the study with NPs in attendance, they will be encouraged to take

ownership in providing optimal care to heart failure patients, and begin a related research study

of their own in the field. This study in and of itself will not be enough on its own to encourage

policymakers to provide more support for expansion of the nurse practitioner scope of practice

and independence, but can serve as a foundational and supportive research study for it in the

future.


31

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Appendix A: Instrument

This is a self-made Excel document with data on fictitious patients, with their numbers of heart

failure admissions and a code for their provider-type, with “1” = physician and “2” = NP


37

Appendix B: IRB Application


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39


40

Documents

Provider-type and Heart Failure Hospitalizations - ScholarWorks