The paper “Nurse practitioners’ completion of Physician Orders for Scope of Treatment (POST) forms in West Virginia: A secondary analysis of 12 months of data from the state registry,” by Lori Anne Constantine, DNP, Toni Dichiacchio, DNP, Evan C. Falkenstine, Alvin H. Moss, MD, was recently published to the Journal of the American Association of Nurse Practitioners. (West Virginia’s POLST Paradigm Program is called POST, or the Physician Orders for Scope of Treatment.)
The purpose of the study was see what, if any differences in POST Forms were associated with the fact that NPs, as opposed to physicians, completed them with patients.
In West Virginia, advanced practice registered nurses (which includes nurse practitioners) gained signatory authority for POST Forms in June of 2016, and this study intentionally examined data from the first year (June 1, 2016 through May 31, 2017) in which NPs were granted this authority.
Specific research questions examined included:
- What proportion of POST Forms are completed by NPs?
- Do NPs in different settings (for example, hospice versus primary care) complete POST Forms differently?
- Are there differences in POST Form completion by discipline: NP versus allopathic physician (MD) versus osteopathic physician (DO)?
- What is the error rate* for NPs in POST completion versus that of other providers?
- Do patients for whom NPs complete POST forms differ from patients for whom other providers complete POST forms?”
*Error rates were specified as the POST being registry ready, meaning fully and correctly completed, versus not registry ready, meaning they were not consider valid orders because they:
- Contained contradictory orders (such as: CPR ordered in section A and comfort or limited additional interventions ordered in section B), and/or
- Were missing patient or provider signatures and dates, and/or
- Had incomplete demographic information.
(As a standard practice, if the WV Center for End-of-Life Care determined the form to be not registry ready, registry staff would attempt to contact patients or providers to rectify concerns.)
Data from 2,992 POST Forms faxed or uploaded to the WV e-Directive Registry between June 1, 2016, and May 31, 2017 were included in this study.
Recent legislation allowing NPs signatory authority for completion of POST forms has affected POST completion among NPs in WV:
- NPs completed and submitted 430, or 14.4% of the 2,992 POST forms completed.
- Only 45 of the almost 2000, or just above 2% of NPs licensed in WV executed POST forms (in the first year of signatory authority to do so, the time frame for this study). For comparison, approximately 10% of POLST Forms in Oregon are completed (signed) by NPs, a state in which NPs have held signatory authority for POLST since 2001.
- 11 of the 45 NPs who completed POST Forms completed many more than the rest, executing 314 (73.0%) of the total NP-signed forms.
- 10 of these 11 were NPs practicing in relatively newer areas of NP practice, community, and hospital-based palliative care providing specialist palliative care as opposed to primary palliative care.
- Nurse practitioners in these 2 specialist palliative care settings completed an average of more than 25 forms each; in comparison, the median number of POST Forms completed overall per NP was 1.
In addition, there were differences in POST Form completion by discipline. Nurse practitioners more often completed:
- POST Forms with DNR orders than MDs or DOs, and
- POST Forms with comfort measure orders than MDs or DOs.
- POST Forms that were registry ready (error free) compared with those submitted by MDs and DOs.
Demographic data of patients who completed POST forms with NPs were compared with those completed with MDs and DOs:
- There were no significant associations between provider type completing the POST and either the patient’s age or gender.
- Most of the POST forms submitted by NPs were for patients who lived in urban settings (64.8%), whereas most of the POST forms submitted by DOs were for patients who lived in rural settings.
Highlights from this study include:
- 14.4% of all POST Forms submitted to the WV e-Directive Registry were completed by NPs, an “impressive number”; in comparison, to after 5 years of POLST form submission by NPs in Oregon, the proportion of POLST forms submitted by NPs constituted 11.9%.
- For the study period (from June 2016 to May 2017), the number of POST forms signed per WV-licensed provider by provider type was 22% NPs, 25% for MDs, and 65% for DOs. The study authors suggest that the higher relative percentage of POST form completion by DOs “may be related to their higher frequency of caring for patients in nursing homes and in rural areas.”
- Registry-ready (error-free) forms were submitted significantly more often by NPs, with an error rate almost half that of physicians.
- A remarkable proportion of POST forms completed in WV was by 10 NPs working on specialist palliative care teams in the community and the hospital.
- Nurse practitioners ordered DNR and comfort measures significantly more often than did physicians.
Other notes made by the study authors:
The reimbursement policy of WV Medicaid may impede NPs completion of POST forms in hospital and nursing home settings. WVs’ Medicaid state plan does not allow NPs to bill for evaluation and management visits of hospitalized patients or nursing home patients.”
This study has shown that a small number of NPs can significantly affect POST form completion, which has been shown to decrease unwanted hospitalizations and increase hospice enrollment.”
Constantine LA, T Dichiacchio, EC Falkenstine, and AH Moss (2018). “Nurse practitioners’ completion of Physician Orders for Scope of Treatment (POST) forms in West Virginia: A secondary analysis of 12 months of data from the state registry.” Journal of the American Association of Nurse Practitioners (30)1:10-16. View online (limited access).