Clinician Staffing and Quality of Care in US Health Centers
Authors: Q. Wilton Sun, Howard P. Forman, Logan Stern, Benjamin J. Oldfield
Journal: JAMA Network Open (2024)

Importance Health centers are vital primary care safety nets for underserved populations, but optimal clinician staffing associated with quality care is unclear. Understanding the association of clinician staffing patterns with quality of care may inform care delivery, scope-of-practice policy, and resource allocation. Objective To describe the association of clinician staffing models and ratios with quality-of-care metrics in health centers. Design, Setting, and Participants This cross-sectional study of US health centers used data from the 2022 Health Resources and Services Administration Uniform Data System (UDS). Exposure Clinician staffing ratios, expressed as the fraction of full-time equivalents (FTEs) per 1000 visits of physicians, advanced practice registered nurses (APRNs), and physician associates (PAs) to total clinician FTEs at each health center. Main outcomes and measures Percentage of eligible patients receiving the corresponding service or outcome for 14 individual clinical quality metrics collected by the UDS, including infant immunizations; screening for cancer, depression, tobacco use, hypertension, HIV, and glycated hemoglobin levels; weight and body mass index (BMI) assessment; and appropriate statin, aspirin, and/or antiplatelet therapy. Results This analysis of 791 health centers serving 16 114 842 patients (56.6% female) identified 5 clinician staffing models: balanced (similar FTEs of physicians, APRNs, and PAs; 152 [19.2%] of health centers), higher FTEs of APRNs than physicians (174 [22.0%]), higher FTEs of physicians than APRNs (160 [20.2%]), approximately equal FTEs of physicians and APRNs (263 [33.2%]), and large scale (42 [5.3%]). Adjusted linear models showed positive associations between physician FTEs per 1000 visits and cervical (β, 14.9; 95% CI, 3.1-26.7), breast (β, 15.7; 95% CI, 3.2-28.1), and colorectal (β, 18.3; 95% CI, 6.0-30.6) cancer screening. Generalized additive models showed nonlinear positive associations beginning at a physician FTE ratio of 0.45 (95% CI, 0.02-6.22) for infant vaccinations, 0.39 (95% CI, 0.05-2.21) for cervical cancer screening, 0.39 (95% CI, 0.02-1.67) for breast cancer screening, 0.47 (95% CI, 0.00-5.76) for HIV testing, and 0.70 (95% CI, 0.18-19.96) for depression in remission; APRN FTE ratio of 0.45 (95% CI, 0.17-7.46) for adult BMI assessment; and PA FTE ratio of 0.16 (95% CI, 0.11-3.88) for infant vaccinations. Staffing models were not associated with 7 of the 14 metrics analyzed. Conclusions and Relevance In this cross-sectional study of health centers, physician FTE ratio was associated with higher performance in cancer screening, infant vaccinations, and HIV testing; APRN FTE ratio was associated with higher performance in preventative health assessments; and PA FTE ratio was associated with higher performance in infant vaccination. These findings suggest that targeted staffing strategies may be associated with quality of care in certain domains and that tailored approaches to health center staffing based on community-specific needs are warranted.