NP's Care Equal to Doc's, Review Finds

By David Pittman, Washington Correspondent, MedPage Today
Published: December 28, 2012

Expanding the scope of practice for nurse practitioners (NPs) would not diminish quality of care, a literature review found.

In fact, states struggling to meet the growing demand for primary care services should expand scope-of-practice laws for NPs and other advanced practice registered nurses (APRNs), the National Governors Association said in its review of the issue.

The group looked at 22 articles, including 10 published since a 2008 review by the Colorado Healthcare Institute, which the current study sought to expand upon.

"Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures," the report, The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care, released late last week, stated. "Moreover, the studies suggest that NPs may provide improved access to care."

Specifically, the review found:

• NPs provided care that compared with that of physicians in terms of patient satisfaction, time spent with patients, prescribing accuracy, and preventive education
• NPs were capable of successfully managing chronic conditions in patients suffering from hypertension, diabetes, and obesity
• Three analyses found NPs rated favorably in achieving patients' compliance with recommendations and reductions in blood pressure and blood sugar
• A 2003 review found NPs were more likely to work in underserved urban populations and rural areas

The report did note, however, that patients reported a preference for care from a physician for "medical aspects of care" but had no preference when it came to "nonmedical aspects of care."

None of the studies in the review measured the differences in quality, access, or costs between states with more and less restrictive scope-of-practice laws.

To date, 16 states and the District of Columbia allow NPs to practice and prescribe independently of physician supervision, the report noted. The remaining 34 states require some level of physician involvement; 10 of them had pending legislation to expand independence this year.

Meanwhile, an additional 30 million people are expected to gain health coverage by 2016 under the Affordable Care Act. Because of the law's elimination of patient cost sharing for preventive services, the demand for primary care will increase between 15 million and 25 million visits per year by the end of the decade, the report noted, requiring between 4,000 and 7,000 more physicians and straining an already existing shortage of primary care practitioners.

"To better meet the nation's current and growing need for primary care providers, states may want to consider easing their scope of practice restrictions and modifying their reimbursement policies to encourage greater NP involvement in the provision of primary care," the report stated.

But physician groups, most notably the American Academy of Family Physicians (AAFP), have denounced NP-run practices, saying they don't provide a quality equal to that of physician-led groups.

Family physicians receive 11 years of training compared with 5.5 to 7 years for an NP, the AAFP said. Physicians also are required to complete about four times more clinical hours than NPs in order to practice.

Some critics believe medical societies like the AAFP oppose NP independence because of financial concerns, but the governors' report dismissed that concern: "It is important to note that a recent analysis shows no variation in physician earnings between states that have expanded APRN scope of practice laws and states that have not," the report stated, citing a November study in the journal Nursing Practice and Research.

A 2010 report from the Institute of Medicine slammed state laws that prevent NPs and other APRNs from practicing to their fullest extent, noting that laws and regulations have failed to keep pace with nursing's evolution in the past 40 years.

In 2011, Kaiser Permanente expanded the role of NPs from team member to clinic lead in a Colorado prenatal clinic -- a state with more flexible scope-of-practice laws.

"Although it is too early to compare the total cost of the prenatal clinic led by NPs with the cost of prenatal clinics led by physicians, all other metrics have been found to be indistinguishable between the two models," the report stated.

But Kaiser is so satisfied with its early results that it is planning to expand its NP-led model to additional prenatal clinics in Colorado.