Primary Care Nurse Practitioner Work Environments and Hospitalizations and ED Use Among Chronically Ill Medicare Beneficiaries

Lusine Poghosyan, Jianfang Liu, Jennifer Perloff, Thomas D'Aunno, Kenrick D. Cato, Mark W. Friedberg, Grant Martsolf

Research output: Contribution to journalArticlepeer-review


Background: Nurse practitioners (NPs) play a critical role in delivering primary care, particularly to chronically ill elderly. Yet, many NPs practice in poor work environments which may affect patient outcomes. Objective: We investigated the relationship between NP work environments in primary care practices and hospitalizations and emergency department (ED) use among chronically ill elderly. Research Design: We used a cross-sectional design to collect survey data from NPs about their practices. The survey data were merged with Medicare claims data. Subjects: In total, 979 primary care practices employing NPs and delivering care to chronically ill Medicare beneficiaries (n=452,931) from 6 US states were included. Measures: NPs completed the Nurse Practitioner-Primary Care Organizational Climate Questionnaire-a valid and reliable measure for work environment. Data on hospitalizations and ED use was obtained from Medicare claims. We used Cox regression models to estimate risk ratios. Results: After controlling for covariates, we found statistically significant associations between practice-level NP work environment and 3 outcomes: Ambulatory Care Sensitive (ACS) ED visits, all-cause ED visits, and all-cause hospitalizations. With a 1-unit increase in the work environment score, the risk of an ACS-ED visit decreased by 4.4% [risk ratio (RR)=0.956; 99% confidence interval (CI): 0.918-0.995; P=0.004], an ED visit by 3.5% (RR=0.965; 99% CI: 0.933-0.997; P=0.005), and a hospitalization by 4.0% (RR=0.960;99% CI: 0.928-0.993; P=0.002). There was no relationship between NP work environment and ACS hospitalizations. Conclusion: Favorable NP work environments are associated with lower hospital and ED utilization. Practice managers should focus on NP work environments in quality improvement strategies.

Original languageEnglish (US)
Pages (from-to)496-503
Number of pages8
JournalMedical care
Issue number7
StatePublished - Jul 1 2022


  • emergency department visit
  • hospitalizations
  • nurse practitioner
  • primary care
  • work environment

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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