NP Facts

NPs decrease ER visitsLoyola University Health System researchers said the addition of a nurse practitioner to an emergency care team significantly cut unnecessary emergency department visits. The nurse practitioner also helped improve utilization of emergency department resources, according to the study published in Surgery. BeckersASC.com (11/7)     

Health care law drives demand for NPs
Advanced practice nurses are expected to have greater presence in primary care and other specialty areas facing physician shortage, driven in part by coverage expansion under the health care law. "On almost all of the observable dimensions that anyone can identify, nurse practitioners, physician assistants, and other similarly trained professionals can provide primary care that equals the average quality of primary care provided by physicians," economist Mark Pauly noted in the journal Health Affairs. The Oregonian (Portland)

NPs' role should be expanded, not disparaged or discounted
Expanding the role of nurse practitioners is an obvious solution to the shortage of health care providers, and some states' restrictions as well as some disparaging attitudes need to be overcome, writes NP Robyn Carlisle. She points to a review in the journal Nursing Economic$ that said "the ideal health system comprises multiple providers who communicate with and are accountable to each other to deliver coordinated care." ClinicalAdvisor.com (8/11)

NPs see greater acceptance, greater demand
Nurse practitioners have gained increased acceptance from patients and doctors as they have expanded their roles and authority, including more training and practice in specialty areas. "Nurse practitioners are going to be utilized more in primary care," said Julia Spinolo, DNP, of Clayton State University. The Atlanta Journal-Constitution (3/21)

Growing provider need spurs more demand for NPs,
A move toward cost-effective and collaborative health care has heightened the demand for nurse practitioners and physician assistants. This trend suggests physicians "will care for the most complex patients and deal with overall practice management issues. PAs and NPs will be used more extensively to provide the bulk of primary care practice," said Anita Duhl Glicken from the University of Colorado School of Medicine. ClinicalAdvisor.com

 U.S. sees major increase in number of NPs
The number of nurse practitioner graduates in the U.S. increased by 75% during the past five years, according to data from AANP. One reason for the increase may be the growing public awareness of NPs' role in the health care community. "I think as registered nurses become more aware of that role, and what we do, they're proceeding to that next level of education," said Kathy Morris, coordinator of the family NP program at the University of Nebraska Medical Center. Fremont Tribune (Neb.) (3/10)

Internists Issue Policy Statements on Critical Roles of Physicians and Nurse Practitioners in Improving Access to Care

 
American College of Physicians Recognizes Common Goals of Providing High-Quality, Patient-Centered Care and Improving Health Status of Those They Serve

 
 Washington, February 17, 2009 – “The American College of Physicians (ACP) has always recognized the unique role that a personal physician plays in meeting the needs of individual patients,” Jeffrey P. Harris, MD, FACP, president of the American College of Physicians, noted today upon the release of  a new policy monograph.  “But even the most committed physician can’t do it alone.  Today, ACP shares its ideas on how nurse practitioners and physicians can work together—as teammates that respect and recognize each profession’s unique contributions and skills—to provide patients with the best possible care.”

 
By covering seven positions, Nurse Practitioners in Primary Care updates and clarifies ACP stands in areas that include:

• Coverage of physician and NP training, knowledge, skills and abilities
• Coordinated care to of primary importance in improving health outcomes
• Licensing and certification exams
• Multidisciplinary care in the patient-centered medical home model
• Research efforts for patient management among physicians and NPs
• Education and training of all health professionals
• Workforce policies to improve patient access to quality care

The 18-page monograph’s executive summary notes that “anticipated and actual shortages of primary care physicians have led policymakers to consider the roles of nurse practitioners (NPs) in improving access to primary health care services.  “Physicians and nurse practitioners not only share a commitment to providing high quality care, the paper says, but also face similar challenges regarding reimbursement and workforce outlook.  Recognizing and building on the common ground between the two professions is vital to improving collaboration to meet the complex health care needs of the population.

 However, the paper also cautions “that advanced practice nursing should not substitute for, or replace, primary care medical practice as provided by general internists, family physicians and other physicians.” 

 “The ACP hopes that this paper will strengthen the dialogue between the medical and nurse practitioner communities to improve future health care delivery,” said Dr. Harris. “A high-quality and efficient health care system requires effective multidisciplinary teams that collaborate to provide patient-centered care.”

Over the past 20 years, the ACP paper notes, an increase in the numbers of nurse practitioners, enactment of state laws expanding scope of practice, prescriptive authority and third-party reimbursement, and national efforts to improve health care access, have resulted in expanded roles for NPs in providing primary care services.  However, greater autonomy of NPs has been a point of contention between the medical and advanced practice nursing communities.  At times, questions have been raised about the adequacy of NP training and certification, comparisons drawn by NPs to the care delivered by physicians, quality of patient outcomes and perceived intentions to displace or replace primary care physicians. 

 
ACP’s paper cited a study by the Association of American Medical Colleges that warns that the demand in the coming years for primary care physicians will outpace supply faster for primary care than for any other specialty group.  It notes that another study published in Health Affairs projects a growing shortage of primary care physicians for adults, even as the contributions of nurse practitioners, as essential members of the primary care workforce, are taken into account.

 In the process of developing its recommendations, ACP consulted with highly-regarded members of the nursing profession to gain a better understanding of their perspectives.

ACP intends to continue its dialogue with nurse practitioners, and to similarly engage in discussions with other professions—particularly physicians assistants—who play a vital role in meeting the nation’s growing need for primary care.

 “The key to high performance in multi-disciplinary teams is an understanding of the distinctive roles, skills, and values of all team members,” Dr. Harris concluded.  “Our hope is that ACP’s new paper will help contribute to  a better  understanding  of how  physicians and nurse practitioners can work together to provide patients with the best care possible.”

 
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 126,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illness in adults.

Analysis: Differences between NPs and PAs
Nurse practitioners and physician assistants are two growing professions with seemingly similar roles, but the positions differ in many ways, from education to clinical practice. Nurse practitioners are licensed as independent health care providers, often train in a specialty and are licensed by state boards of nursing, while PAs must practice under a physician's supervision, are generalists and are licensed by state boards of medicine. The New York Times (8/9/08)

CURRENT RESEARCH:

Avorn, J., Everitt, D.E., & Baker, M.W. (1991). The neglected medical history and therapeutic choices for abdominal pain. A nationwide study of 799 physicians and nurses. Archives of Internal Medicine, 151 (4), 694-698.
A sample of 501 physicians and 298 NPs participated in a study by responding to a hypothetical scenario regarding epigastric pain in a patient with endoscopic findings of diffuse gastritis. They were able to request additional information before recommending treatment. Adequate history-taking resulted in identifying use of aspirin, coffee, igarettes, and alcohol, paired with psychosocial stress. Compared to NPs, physicians were more likely to prescribe without seeking relevant history. NPs, in contrast, asked more questions and were less likely to recommend prescription medication.

 Brown, S.A. & Grimes, D.E. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary care. Nursing Research, 44 (6) 332-9.
A meta-analysis of 38 studies comparing a total of 33 patient outcomes of NPs with those of physicians demonstrated that NP outcomes were equivalent to or greater than those of physicians. NP patients had higher levels of compliance with recommendations in studies where provider assignments were randomized and when other means to control patient risks were used. Patient satisfaction and resolution of pathological conditions were greatest for NPs. The NP and physician outcomes were equivalent on all other outcomes. 

Congressional Budget Office (1979). Physician extenders: Their current and future role in medical care delivery. Washington, D.C.:USGovernment Printing Office.
As early as 1979, the Congressional Budget Office reviewed findings of the numerous studies of NP performance in a variety of settings and concluded that NPs performed as well as physicians with respect to patient outcomes, proper diagnosis, management of specified medical conditions, and frequency of patient satisfaction.

 Cooper, M.A., Lindsay, G.M., Kinn, 5., Swann, I.J. (2002). Evaluating emergency nurse practitioner services: Arandomized controlled trial. Journal of Advanced Nursing, 40 (6).
A study of 199 patients randomly assigned to emergency NP-Iedcare or physician-led care in the U.K. demonstrated the highest level of satisfaction and clinical documentation for NP care. The outcomes of recovery time, symptom level, missed work, unplanned follow-up, and missed injuries were comparable between the two groups.

Ettner, s.L., Kotlerman, J., Abdelmonem, A., Vazirani, 5., Hays, R.D., Shapiro, M., Cowan, M.(2006).
An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Medical Decision Making, 26, 9-17. Significant cost savings were demonstrated when 1207patients in an academic medical center were randomized to either standard treatment or to a physician-NP model.

 Horrocks,S., Anderson, E.,Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324, 819-823.
A systematic review of 11 randomized clinical trials and 23 observational studies identified data on outcomes of patient satisfaction, health status, cost, and/or process of care. Patient satisfaction was highest for patients seen by NPs. The health status data and quality of care indicators were too heterogeneous to allow for meta-analysis, although qualitative comparisons of the results reported showed comparable outcomes between NPs and physicians. NPs offered more advice/information, had more complete  documentation, and had better communication skills than physicians. NPs spent longer time with their patients and performed a greater number of investigations than did physicians. No differences were detected in health status, prescriptions, return visits, or referrals. Equivalency in appropriateness of studies and interpretations of x-rays were identified. 

Larkin, H. (2003). The case for nurse practitioners. Hospitals and Health Networks Aug 2003, 54-59.
The author describes compelling statistics supporting the case of NPs, including several studies demonstrating decreased inpatient days, decreased ventilator days, improved heart failure outcomes, and decreased complications such as skin lesions, urinary tract infections, and pneumonia. 

Laurant, M.; Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sib bald, B. (2006). Substitution of doctors by nurses in primary care. Cochrane Database of systematic reviews. 2006, Issue 1.
This meta-analysis included 25 articles relating to 16 studies comparing outcomes of primary care nurses (nurses, NPs, clinical nurse specialists, or advance practice nurses) and physicians. The quality of care provided by nurses was as high as that of the physicians. Overall, health outcomes and outcomes such as resource utilization and cost were equivalent for nurses and physicians. The satisfaction level was higher for nurses. Studies included a range of care delivery models, with nurses providing first contact, ongoing care, and urgent care for many of the patient cohorts.

 Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care Research and Review 61 (3), 332-351.
The outcomes of care in the study described by Mundinger, et al in 2000 (see below) are further described in this report including two years of follow-up data, confirming continued comparable outcomes for the two groups of patients. No differences were identified in health status, physiologic measures, satisfaction, or use of specialist, emergency room, or to NPs. inpatient services. Patients assigned to physicians had more primary care visits than those assigned assigned to NPs. 

Lin, S.X., Hooker, R.S., Lens, E.R., Hopkins, S.C. (2002). Nurse practitioners and physician assistants in hospital outpatient departments, 1997-1999. Nursing Economics, 20 (4), 174-179.
Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to identify patterns of NP and PA practice styles. NPs were more likely to see patients alone and to be involved in routine examinations, as well as care directed towards wellness, health promotion, disease prevention, and health education than PAs, regardless of the setting type. In contrast, PAs ere more likely to provide acute problem management and to involve another person, such as a support staff person or a physician.

 Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y.,Cleary, P.D., Friedewald, W.T., Siu, A.L., & Primary care outcomes in patients treated by nurse practitioners or physicians: A Shelanski, M.L. (2000). randomized trial. JAMA, 283 (1), 59-68.
The outcomes of care were measured in a study where patients were randomly assigned either to a physician or to an NP for primary care between 1995 and 1997, using patient interviews and health services utilization data. Comparable outcomes were identified, with a total of 1316 patients. After six months of care, health status was equivalent for both patient groups, although patients treated for hypertension by NPs had lower diastolic values. Health service utilization was equivalent at both 6 and 12 months and patient satisfaction was equivalent following the initial visit. At six months, physicians rated higher on one component of the satisfaction scale. 

Office of Technology Assessment (1986). Nurse practitioners, {?hysician assistants, and certified nurse Office. midwives: A policy analysis. Washington D.C.: US Government Printing
The Office of Technology Assessment reviewed studies comparing NP and physician practice, concluding that, "NPs appear to have better communication, counseling, and interviewing skills than physicians have." (p. 19) and that malpractice premiums and rates supported patient satisfaction with NP care, pointing out that successful malpractice rates against NPs remained extremely rare. 

Prescott, P.A. & Driscoll, L. (1980). Evaluating nurse practitioner performance. Nurse Practitioner, 1 (1),28-32.
The authors reviewed 26 studies comparing NP and physician care, concluding that NPs scored higher in many areas. These included: amount/depth of discussion regarding child health care, preventative health, and wellness; amount of advice, therapeutic listening, and support offered to patients; completeness of history and follow-up on history  findings; completeness of physical examination and interviewing skills; and patient knowledge of the management plan given to them by the provider.

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