Nurse Practitioner Care Environments and Provider Shortages Among Patients With Multiple Chronic Conditions

In health professional shortage areas (HPSAs), primary care providers face challenges due to high workloads and limited resources, impacting their ability to provide comprehensive care to patients with multiple chronic conditions (MCCs). In addition, patients in HPSA compared to non-HPSA settings experience poorer outcomes. Nurse practitioners (NPs) play a crucial role in meeting MCC patients' needs, but some work in unfavorable care environments (e.g., lacking teamwork, support, and autonomy) that hinder their capacity to manage complex chronic diseases. This study examines the effect of NP care environments on the relationship between HPSA status and hospitalizations or emergency department (ED) visits among patients with MCCs. We conducted a secondary analysis of merged Medicare claims, NP survey data, and Health Resources and Services Administration data. Our sample included 779 practices with 394,424 Medicare beneficiaries aged 65+ who had at least two of 15 chronic conditions. We used logistic regression to evaluate the impact of HPSA status and the NP care environment on ED visits or hospitalizations. NP care environments moderate the association between HPSA status and hospitalization (AOR 1.165, 95% CI [1.037-1.309], p = 0.010) but not ED use. Improved care environments are associated with lower odds of hospitalization in non-HPSAs (β = -0.148, 95% CI [-0.225, -0.072], p = 0.0001), while in HPSAs, improved care environments have no effect on hospitalization odds (β = 0.0047, 95% CI [-0.086, 0.096], p = 0.920). Addressing provider shortages in HPSAs may allow an improved NP care environment to produce maximal benefits for patients.