Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states

AimsTo understand patients- and providers- perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System.DesignQualitative exploratory study (in convergent mixed- methods design).MethodsSemi- structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis.ResultsWe interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers- professional experience outweighed provider type.ConclusionsPatients- preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers- perceptions suggest NPs and physicians are both viable providers for primary care.ImpactNurse Practitioners (NPs): practice authorityVeterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care deliveryUnited States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much- needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiencesæ è¦ ç ®æ  äº è§£æ £è å å »ç æ ºæ 对é ä¼ å äººå »ç ä¿ å ¥ç³»ç» ä¸­æ ¤ç å¸ æ ä¾ å çº§æ ¤ç ç ç æ³ ã è®¾è®¡æ ¢ç´¢æ §ç å® æ §ç  ç©¶(æ ¶æ æ··å æ ¹æ³ è®¾è®¡)ã æ ¹æ³ 2016å¹´è¿ è¡ ç å ç» æ å è®¿è° ,é è®¿äº å· å æ ¥æ æ ¤ç å¸ ç å ¨ç§ å é å ¨ç§ æ §ä¸ æ ºæ ç å çº§æ ¤ç æ ä¾ è å æ £è ã é æ °å é æ £è æ ·æ ¬:(a) ä¸ å æ ¤ç å¸ ;æ (b)ç¡®ç« å »ç å ³ç³»ç å ¦ä¸ å å »ç ã é ç ¨å 容å æ æ³ å¯¹æ °æ ®è¿ è¡ å æ ã ç» æ æ 们é è®¿äº 28å æ £è ,17å å »ç å 14å æ ¤ç å¸ ã æ 们å ç °:(a)æ ¤ç å¸ æ¯ å »ç æ ä¾ ç æ ¤ç æ ´å ¨é ¢;(b)æ £è å¯¹æ ¤ç å¸ æ å °æ»¡æ ;(c)å »ç æ ºæ ç ä¸ ä¸ ç» éª ç æ é æ¯ å »ç æ ºæ ç±»å ç æ é æ ´å¤§ã ç» è®ºæ £è å¯¹æ ¤ç å¸ ç å 好(ä¸ ä»¥å ç å »ç ç ¸æ¯ )æ å ©äº å»ºç« ä»¥æ £è ä¸ºä¸­å¿ ç è®¤ç ¥ã æ ä¾ è ç è§ å¿µç±»ä¼¼,表æ æ ¤ç å¸ å å »ç é ½æ ¯å ¯è¡ ç å çº§æ ¤ç æ ä¾ è ã å½±å - ¢æ ¤ç å¸ :æ §ä¸ æ ºæ - ¢é ä¼ å äººå »ç ä¿ å ¥ç³»ç» :æ ¤ç å¸ å° ç»§ç»­ä½ ä¸ºæ ä¾ å çº§æ ¤ç æ å ¡ç å ¯ç ¨èµ æº ã - ¢ç¾ å ½å «ç ä¿ å ¥:æ æ è§ å¿µ æ £è å ¯è ½ä¸ æ»¡æ ç ±æ ¤ç å¸ æ ä¾ ç æ ¤ç ,å ¶ä¼ æ ¯æ æ ©å¤§ä½¿ç ¨è å ´,以æ ä¾ æ ¥é ç å çº§ä¿ å ¥æ å ¡;æ ©å¤§å ¨ç§ æ §ä¸ æ ºæ å° ä½¿å å· è ½å¤ æ ä¾ å ¯æ ¥å ç å çº§ä¿ å ¥æ å ¡,è ä¸ ä¼ å å¼±æ £è æ æ ä¾ è ç ä½ éª ãPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163369/2/jan14501.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163369/1/jan14501_am.pd

Detection of B-mode Polarization in the Cosmic Microwave Background with Data from the South Pole Telescope

Gravitational lensing of the cosmic microwave background generates a curl pattern in the observed polarization. This "B-mode" signal provides a measure of the projected mass distribution over the entire observable Universe and also acts as a contaminant for the measurement of primordial gravity-wave signals. In this Letter we present the first detection of gravitational lensing B modes, using first-season data from the polarization-sensitive receiver on the South Pole Telescope (SPTpol). We construct a template for the lensing B-mode signal by combining E-mode polarization measured by SPTpol with estimates of the lensing potential from a Herschel-SPIRE map of the cosmic infrared background. We compare this template to the B modes measured directly by SPTpol, finding a non-zero correlation at 7.7 sigma significance. The correlation has an amplitude and scale-dependence consistent with theoretical expectations, is robust with respect to analysis choices, and constitutes the first measurement of a powerful cosmological observable.Comment: Two additional null tests, matches version published in PR

A Measurement of the Cosmic Microwave Background Damping Tail from the 2500-square-degree SPT-SZ survey

We present a measurement of the cosmic microwave background (CMB) temperature power spectrum using data from the recently completed South Pole Telescope Sunyaev-Zel'dovich (SPT-SZ) survey. This measurement is made from observations of 2540 deg$^2$ of sky with arcminute resolution at $150\,$GHz, and improves upon previous measurements using the SPT by tripling the sky area. We report CMB temperature anisotropy power over the multipole range $650<\ell<3000$. We fit the SPT bandpowers, combined with the seven-year Wilkinson Microwave Anisotropy Probe (WMAP7) data, with a six-parameter LCDM cosmological model and find that the two datasets are consistent and well fit by the model. Adding SPT measurements significantly improves LCDM parameter constraints; in particular, the constraint on $\theta_s$ tightens by a factor of 2.7. The impact of gravitational lensing is detected at $8.1\, \sigma$, the most significant detection to date. This sensitivity of the SPT+WMAP7 data to lensing by large-scale structure at low redshifts allows us to constrain the mean curvature of the observable universe with CMB data alone to be $\Omega_k=-0.003^{+0.014}_{-0.018}$. Using the SPT+WMAP7 data, we measure the spectral index of scalar fluctuations to be $n_s=0.9623 \pm 0.0097$ in the LCDM model, a $3.9\,\sigma$ preference for a scale-dependent spectrum with $n_s<1$. The SPT measurement of the CMB damping tail helps break the degeneracy that exists between the tensor-to-scalar ratio $r$ and $n_s$ in large-scale CMB measurements, leading to an upper limit of $r<0.18$ (95%,C.L.) in the LCDM+$r$ model. Adding low-redshift measurements of the Hubble constant ($H_0$) and the baryon acoustic oscillation (BAO) feature to the SPT+WMAP7 data leads to further improvements. The combination of SPT+WMAP7+$H_0$+BAO constrains $n_s=0.9538 \pm 0.0081$ in the LCDM model, a $5.7\,\sigma$ detection of $n_s < 1$, ... [abridged]Comment: 21 pages, 10 figures. Replaced with version accepted by ApJ. Data products are available at http://pole.uchicago.edu/public/data/story12

A CMB lensing mass map and its correlation with the cosmic infrared background

We use a temperature map of the cosmic microwave background (CMB) obtained using the South Pole Telescope at 150 GHz to construct a map of the gravitational convergence to z ~ 1100, revealing the fluctuations in the projected mass density. This map shows individual features that are significant at the ~ 4 sigma level, providing the first image of CMB lensing convergence. We cross-correlate this map with Herschel/SPIRE maps covering 90 square degrees at wavelengths of 500, 350, and 250 microns. We show that these submillimeter-wavelength (submm) maps are strongly correlated with the lensing convergence map, with detection significances in each of the three submm bands ranging from 6.7 to 8.8 sigma. We fit the measurement of the cross power spectrum assuming a simple constant bias model and infer bias factors of b=1.3-1.8, with a statistical uncertainty of 15%, depending on the assumed model for the redshift distribution of the dusty galaxies that are contributing to the Herschel/SPIRE maps.Comment: 5 pages, 3 figures, to be submitted to ApJ

CMB Polarization B-mode Delensing with SPTpol and Herschel

We present a demonstration of delensing the observed cosmic microwave background (CMB) B-mode polarization anisotropy. This process of reducing the gravitational-lensing generated B-mode component will become increasingly important for improving searches for the B modes produced by primordial gravitational waves. In this work, we delens B-mode maps constructed from multi-frequency SPTpol observations of a 90 deg$^2$ patch of sky by subtracting a B-mode template constructed from two inputs: SPTpol E-mode maps and a lensing potential map estimated from the $\textit{Herschel}$ $500\,\mu m$ map of the CIB. We find that our delensing procedure reduces the measured B-mode power spectrum by 28% in the multipole range $300 < \ell < 2300$; this is shown to be consistent with expectations from theory and simulations and to be robust against systematics. The null hypothesis of no delensing is rejected at $6.9 \sigma$. Furthermore, we build and use a suite of realistic simulations to study the general properties of the delensing process and find that the delensing efficiency achieved in this work is limited primarily by the noise in the lensing potential map. We demonstrate the importance of including realistic experimental non-idealities in the delensing forecasts used to inform instrument and survey-strategy planning of upcoming lower-noise experiments, such as CMB-S4.Comment: 17 pages, 10 figures. Comments are welcome

Measurements of the Temperature and E-Mode Polarization of the CMB from 500 Square Degrees of SPTpol Data

We present measurements of the $E$-mode polarization angular auto-power spectrum ($EE$) and temperature-$E$-mode cross-power spectrum ($TE$) of the cosmic microwave background (CMB) using 150 GHz data from three seasons of SPTpol observations. We report the power spectra over the spherical harmonic multipole range $50 < \ell \leq 8000$, and detect nine acoustic peaks in the $EE$ spectrum with high signal-to-noise ratio. These measurements are the most sensitive to date of the $EE$ and $TE$ power spectra at $\ell > 1050$ and $\ell > 1475$, respectively. The observations cover 500 deg$^2$, a fivefold increase in area compared to previous SPTpol analyses, which increases our sensitivity to the photon diffusion damping tail of the CMB power spectra enabling tighter constraints on \LCDM model extensions. After masking all sources with unpolarized flux $>50$ mJy we place a 95% confidence upper limit on residual polarized point-source power of $D_\ell = \ell(\ell+1)C_\ell/2\pi <0.107\,\mu{\rm K}^2$ at $\ell=3000$, suggesting that the $EE$ damping tail dominates foregrounds to at least $\ell = 4050$ with modest source masking. We find that the SPTpol dataset is in mild tension with the $\Lambda CDM$ model ($2.1\,\sigma$), and different data splits prefer parameter values that differ at the $\sim 1\,\sigma$ level. When fitting SPTpol data at $\ell < 1000$ we find cosmological parameter constraints consistent with those for $Planck$ temperature. Including SPTpol data at $\ell > 1000$ results in a preference for a higher value of the expansion rate (H_0 = 71.3 \pm 2.1\,\mbox{km}\,s^{-1}\mbox{Mpc}^{-1} ) and a lower value for present-day density fluctuations ($\sigma_8 = 0.77 \pm 0.02$).Comment: Updated to match version accepted to ApJ. 34 pages, 17 figures, 6 table

Measurements of Sub-degree B-mode Polarization in the Cosmic Microwave Background from 100 Square Degrees of SPTpol Data

We present a measurement of the $B$-mode polarization power spectrum (the $BB$ spectrum) from 100 $\mathrm{deg}^2$ of sky observed with SPTpol, a polarization-sensitive receiver currently installed on the South Pole Telescope. The observations used in this work were taken during 2012 and early 2013 and include data in spectral bands centered at 95 and 150 GHz. We report the $BB$ spectrum in five bins in multipole space, spanning the range $300 \le \ell \le 2300$, and for three spectral combinations: 95 GHz $\times$ 95 GHz, 95 GHz $\times$ 150 GHz, and 150 GHz $\times$ 150 GHz. We subtract small ($< 0.5 \sigma$ in units of statistical uncertainty) biases from these spectra and account for the uncertainty in those biases. The resulting power spectra are inconsistent with zero power but consistent with predictions for the $BB$ spectrum arising from the gravitational lensing of $E$-mode polarization. If we assume no other source of $BB$ power besides lensed $B$ modes, we determine a preference for lensed $B$ modes of $4.9 \sigma$. After marginalizing over tensor power and foregrounds, namely polarized emission from galactic dust and extragalactic sources, this significance is $4.3 \sigma$. Fitting for a single parameter, $A_\mathrm{lens}$, that multiplies the predicted lensed $B$-mode spectrum, and marginalizing over tensor power and foregrounds, we find $A_\mathrm{lens} = 1.08 \pm 0.26$, indicating that our measured spectra are consistent with the signal expected from gravitational lensing. The data presented here provide the best measurement to date of the $B$-mode power spectrum on these angular scales.Comment: 21 pages, 4 figure

A Measurement of the Cosmic Microwave Background Gravitational Lensing Potential from 100 Square Degrees of SPTpol Data

We present a measurement of the cosmic microwave background (CMB) gravitational lensing potential using data from the first two seasons of observations with SPTpol, the polarization-sensitive receiver currently installed on the South Pole Telescope (SPT). The observations used in this work cover 100 deg$^2$ of sky with arcminute resolution at 150 GHz. Using a quadratic estimator, we make maps of the CMB lensing potential from combinations of CMB temperature and polarization maps. We combine these lensing potential maps to form a minimum-variance (MV) map. The lensing potential is measured with a signal-to-noise ratio of greater than one for angular multipoles between $100< L <250$. This is the highest signal-to-noise mass map made from the CMB to date and will be powerful in cross-correlation with other tracers of large-scale structure. We calculate the power spectrum of the lensing potential for each estimator, and we report the value of the MV power spectrum between $100< L <2000$ as our primary result. We constrain the ratio of the spectrum to a fiducial $\Lambda$CDM model to be $A_{\rm MV}=0.92 \pm 0.14 {\rm\, (Stat.)} \pm 0.08 {\rm\, (Sys.)}$. Restricting ourselves to polarized data only, we find $A_{\rm POL}=0.92 \pm 0.24 {\rm\, (Stat.)} \pm 0.11 {\rm\, (Sys.)}$. This measurement rejects the hypothesis of no lensing at $5.9 \sigma$ using polarization data alone, and at $14 \sigma$ using both temperature and polarization data.Comment: 16 pages, 8 figure