Study finds primary care given by NP's and MD's comparable

  1. I found the results of this research study interesting. It found that the outcomes of both Nurse Practitioner and MD primary care were similar in almost every case....


    Stevern21



    http://www.rwjf.org/portfolios/resou...6.htm&iaid=133
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  2. 14 Comments

  3. by   Wile E Coyote
    Having worked alongside some stellar RN's over my few years, this doesn't surprise me at all. Med school doesn't, by default, make you the smartest person in the room for the job at hand.
  4. by   caldje
    Why do you think this study shows any validity? Would you like to discuss why it is valid or why it is not? It is very hard to say that because this study of a couple hundred patients who saw their doc or NP once or twice within the study period means NP care is as good as MD care. MDs by default get the more complex and critical cases and no two patients respond the same way. It is a matter of chance when you follow that few of patients for such a short time as to which provider is going to have the healthier patients and thats all this study showed. No CAUSAL relationship. Even the study itself admits it couldnt find statistically significant differences because of the small sample size, not because of equal care. Also consider what conditions were being treated.. Anyone could be trained in a few weeks to treat hypertension, diabetes, and asthma.
  5. by   wildmountainchild
    Whoa Caldje....a bit angry are we? Maybe it's been a while since you took statistics but if your sample population is chosen carefully in regards to control parameters, and remains smaller than 10% of the population being studied, statistically relevant data can be obtained. Over 700 patients is more than enough to represent the populaiton at large (do you think they poll every single person in the U.S. when they do political polls? No, they poll between 500-1000 people and get amazingly accurate results)

    I don't even remember the last time I saw an actual Dr., NP's are the standard of care with almost everyone I talk to.....and we are all very, very impressed w/ the care we get.

    And...you are reading the study incorrectly, possibly due to your unfamiliarity with statistics. The study couldn't find statistically significant differences because there WERE NONE. The patients were controlled for the type of illnessess they were presenting with, the MD's were not getting the more complex cases. This is clearly stated in the article.

    I think the question is less about the validity of the study and more about what you have to lose if NP's are treated as medical professionals.
  6. by   caldje
    wow... no, Im not angry at all. I have nothing to lose if NPs are shown equal to MDs. I dont know how you can say "NPs are the standard of care" and I would like to hear you elaborate on it. But no, I am not angry at all, I simply wanted to start a conversation on the study being presented instead of a doctor bashing fest. You have no idea who I am, can you refrain from the antagonistic remakrs and lets talk about the study?
  7. by   caldje
    Now, I'll just address one issue in the study. It states that they chose patients with the same health status at the beginning of the study. How did they do that? What do they determine is health status? How can you determine who will become ill and who will not? With a small sample size, it is easy for 5-10-50 patients who became ill, to skew the results and "blame it on the doctor." Also, if the patients were healthy, OF COURSE, they stayed healthy throughout the 2 years study. Look, they only cam back to the office an average of 1.76 times in the remaining time of the study, 2.5 times for docs. Seriously ill patients are more likely to have been followed closely, every 3 months or 6 months. There is something that needs exploring here, why did the docs bring their patients in more often? Was it because they were more ill? Also, these patients likely weren't very ill in the first place. You can take an untrained person and give them healthy patients and their outcomes will be comparible to the most knowledgable physicians in the world. The patients are healthy. The issue is, healthy people are not what makes the difference, it is the very sick people we need to be comparing and the study needs to be much more specific, narrow, and with a large sample size. Find a study with 1000 NP patients who have NEVER seen a physician and that the NP did not consult a physician and then we can study them and decide if NPs have give comparible care. Also, narrow it down to a specific condition and aspect of the duties of the docs and NPs. Did they miss the diagnosis, was it the treatment choices, did they order too many imaging and lab studies. Then you would have significant data. I am all in support of NPs, in the role they are trained to provide... Caring for healthy patients with physician oversite. In that case, yes, Id be happy to have an NP care for me and I am sure my outcome would be the same, afterall, Im already healthy. DO some lit searches and find some valid, significant studies that isolate the variables and I'd be happy to agree with you.

    chris
  8. by   travel920
    From my personal experience and that is a sample of one, I have had great care from both Physicians and Nurse Practitioners. I have also seen the care given by inept Physicians. On average I suspect that an MD is likely to know more about WHY than an NP. On the other hand, case load and other issues can and do affect patient outcomes. I have seen Nurse Practitioners in over their head.

    It boils down to individual differences EXCEPT, without question, the education process for a Physician is way more intensive than MSN/NP. And for a final comment, I have seen younger Physicians ask a long time NP for advice in her area of speciality.
  9. by   pickledpepperRN
    I think an NP, like all nurses, will know when to bring in a physician.

    My daughter got such excellent teaching by an NP. She was shown charts and tables. It scared her enough that she is now eating healthy food and exercising regularly. She no longer needs BP meds after losing 70 pounds. I know some people get the same from their physician but she did not. In that office the docs are just too rushed.

    Only anecdotal but how many anecdotes = data?
  10. by   caldje
    sure, plenty of anecdotals out there, and this is one reason why I am concerned that NPs are on such a crusade to be "equal to" physicians.

    I go to my primary care provider, describe my symptoms and am told I need to see a GI doc because cultures were negative. I go the the GI doc and get passed off on the NP. The NP never touches me, looks at my chart, asks me a couple questions, then walks out and talks to the doc. The FNP then comes in and gives me flagyl and tells me its an infection (even after negative cultures.) She never educates me on not to drink when on the med, but I take the flagyl and dont get better. Finally go see a doc at another office. She says she thinks it is crohns and should have been scoped earlier... scope = positive for crohns. Anecdotal, but personal and the NP never touched me or told me anything about anything. Not so much "education centered" because she was a nurse.

    YES! new docs are new, and need help.. I am not saying that NPs are not equivalent either... just that this study does not show it. Only time will tell, if NPs ever get complete independence.
  11. by   core0
    Quote from wildmountainchild
    Whoa Caldje....a bit angry are we? Maybe it's been a while since you took statistics but if your sample population is chosen carefully in regards to control parameters, and remains smaller than 10% of the population being studied, statistically relevant data can be obtained. Over 700 patients is more than enough to represent the populaiton at large (do you think they poll every single person in the U.S. when they do political polls? No, they poll between 500-1000 people and get amazingly accurate results)

    I don't even remember the last time I saw an actual Dr., NP's are the standard of care with almost everyone I talk to.....and we are all very, very impressed w/ the care we get.

    And...you are reading the study incorrectly, possibly due to your unfamiliarity with statistics. The study couldn't find statistically significant differences because there WERE NONE. The patients were controlled for the type of illnessess they were presenting with, the MD's were not getting the more complex cases. This is clearly stated in the article.

    I think the question is less about the validity of the study and more about what you have to lose if NP's are treated as medical professionals.
    Actually you are reading the study incorrectly. The study compares the care of MD's and NP's. It finds there were no measureable differences in the sample or health outcomes. However, the most telling part of the study is here:
    Limitations

    Due to the small sample size, the researchers had a limited ability to detect statistically significant differences between patients randomized to the nurse practitioner and physician practices.


    This study has already been extensively dissected. The biggest problem is the sample size. 1300 patients is less than the panel of one FP physician. This is spread across an unknown number of providers. If there are 10 providers you are measuring less than 10% of the patients (the current website for the NP group lists 4 providers). This is further diluted by the amount of patients that actually saw the provider. It actually deals with only 600 or so patients. That is not enough to get any good data. For example to look for a blood glucose difference of 10 in the diabetic population a total of more than 80 patients are needed. They did not give the number of patients that this parameter was looked at, but it has to be less than this number. The disappointing part is that they did not report any of the statistical data. I would guess it is because they did not have sufficent power to measure any parameter. The parameters for peak flow for example would be much larger since the standard deviation is much larger.

    Other problems with this study are:
    1. Funding was by the Columbia school of nursing - the entity being studied.
    2. The NP's in the study are all senior faculty members of the Columbia School of Nursing. Hardly a "normal population". Average experience is 19 years.
    3. There were other significant limitations of the study including the transient nature of the population and the overall health status of the patients which is not described.

    It is a shame that this study was published. The Robert Wood Johnson Foundation usually does a better job than this. One of the NP's is a former RWJ fellow so that may explain some things.

    This should have been titled "NP faculty at Columbia School of Nursing show no different outcomes versus MD's in a small patient sample". This is a long way from compareable.

    Another problem in evaluating NP services is that in New York NP practice must be preformed in collaboration with a physician. It is hard to differentiate what portion of the care can be attributed to what provider.

    If NP's are an extension of the physician then this debate does not make any sense. Any advantages or disadvantages would be attributable to the system. Here the proper test would be the difference between MD/NP practice and MD only practice. If you believe that NP's as independent providers are the equivalent or better than a physician you would have to structure this differently. You would have to find a number of NP's that practice independently and find a compareable group of MD's. You would have to match for patient demographics and health conditions. An urban environment such as NYC is a poor place to do this. Either a health care system such as Kaiser with a good data collection system or more likely a rural environment like an AHEC would be idea.

    The main problem is that there is no good data that independent NP practice is equivalent to physician practice. There is poor data that NP practice in other environments is not worse than physician practice.

    David Carpenter, PA-C
  12. by   LuvLondon04
    perhaps this is just my crazy mind at work, but isn't this debate the very reason that we cannot depend on one study alone to tell us about the care of np's v. md's? i read these postings and i think it a bit ridiculous to try and dissect each part of the study for the answer to the care dilemma.

    the simple truth is that both professionals have something to bring to the field of medicine. the np was created to help ease the burden of the overworked physician and offer a higher level of care than a regular nurse (in my opinion, anyway). obviously i don't agree with an np acting as an md yet also don't believe that md's should treat a competent np as an inferior colleague! there is no question that a physician possesses more schooling, but the white coat doesn't make them a demigod or infallible (just as the schooling of the np doesn't make them an md).

    i would hope that a patient would know (or be enlightened to) the difference between the two professionals and would seek a second opinion if they felt that their care was not handled properly- by a physician or an np!
    Last edit by LuvLondon04 on Feb 15, '07
  13. by   core0
    Quote from luvlondon04
    perhaps this is just my crazy mind at work, but isn't this debate the very reason that we cannot depend on one study alone to tell us about the care of np's v. md's? i read these postings and i think it a bit ridiculous to try and dissect each part of the study for the answer to the care dilemma.

    the simple truth is that both professionals have something to bring to the field of medicine. the np was created to help ease the burden of the overworked physician and offer a higher level of care than a regular nurse (in my opinion, anyway). obviously i don't agree with an np acting as an md yet also don't believe that md's should treat a competent np as an inferior colleague! there is no question that a physician possesses more schooling, but the white coat doesn't make them a demigod or infallible (just as the schooling of the np doesn't make them an md).

    i would hope that a patient would know (or be enlightened to) the difference between the two professionals and would seek a second opinion if they felt that their care was not handled properly- by a physician or an np!
    it should be part of any profession to look at data critically. the medical profession has gone through many internal looks and produces continuous quality/outcomes data (there is increasing good data in the nursing realm). the origins of the np profession looked at np's working in collaboration with physicians. along the way the topic of independence came in. there have been studies that show in certain practice environments np's do as well as fellows. others show they do as well as residents. all of the available studies that compare np's to practicing physicians have a number of flaws. so the question remains open on whether independent np practice is compareable to physician practice. if np's are to achieve independent this is a reasonable question to have answered. if np's are going to work in a collaborative mode or have physician supervisors then this question does not need to be asked. instead the question is collaborative practice compareable to physician only practice.

    the original article was groundbreaking and deserved publication in a major medical journal. it showed a new model that deserved to be looked at. the study shown above is an embaressment and a waste of $160k. it does not provide any new information or allow conclusions. as far as i know despite it being done more than 5 years ago it still has not been published in a peer reviewed journal which is equally telling.

    david carpenter, pa-c
  14. by   wildmountainchild
    Yesterday I was at an ER following an NP around. She got an assigment for a 97 yo who had fallen...possible hip fx right? As the NP is going to care for the pt the Doc goes "Oh, you always work up the little old ladies, don't work up this lol, you'll just waste time."

    To which the NP replied "I'm gonna do what I always do".

    So we went to check out the pt's hip. Gave her a full physical assessment and noticed 3+ edema in her legs. This got the NP thinking, why are her legs swollen, why did she fall? The NP ordered blood tests and electrolyte tests which showed elevated phosphate and anemia. She decided to test for G-positive stool and the test came back positive. The x-ray came back negative for hip fx but the long story short is b/c she "always works up the lol" this lol was diagnosed with metatstic bone cancer and admitted to the hospital. It would have been easy to miss.

    She also saw a pt w/ a dissecting thoracic aneurism w/ hemoptosis. She provided excellent care until he could be tranferred to a hospital w/ a cardiothoracic surgeon.

    She also diagnosed and treated an acute MI. A woman with a history of panic attacks that other practitioners may not have taken seriously b/c of her hx of chest pain, young age and rx for ativan.

    The ER doc there loves his NP. He takes the more serious cases and she covers the ER while he is busy. But it's an ER, so he may be taking care of an MVA while she is doing the spinal tap on the 6mo infant, or suturing up the knife wound guy, or intubating the MI and administering meds.

    She works with the entire ER. She listens to her nurses, makes sure she comunicates with the Docs (ie lets them know she has an MI in Rm 1, and a possible cancer in rm 4) but they trust her skill and leave her to do her job. They ask her questions, and she asks them questions. Honestly it's one of the best work enviroments I've ever seen. It is the true representation of what an NP can be.

    The docs there are lucky to have that NP, and they know it, and that NP is lucky to have those docs, and she knows it.

    Now every profession has it's good and it's bad. I had a doc, a urologist who was helping me deal with chronic UTI's. He wnted me to take prophylactic sulpha.....I told him the last time I had taken it I got itchy, although I didn't get a rash. I had a bad feeling about taking it again. He basically bullied me into taking it....said it was my DUTY as a patient to listen to what he was saying, new drugs with different formualtions were coming out all the time and if I wanted to get better I had to go with the flow. So I said O.K. Took a dose that night and ended up the ER for 30 hours. Everytime the epi and benedryl would wear off my face started blowing up like a ballon. I had the nurse call my doc to the hospital and asked him "Do you thtil think iths my DUDY to take thith mdithine?" (It's hard to talk when your lips are 5 x bigger than Angeline Jolie's).

    Now that was only one doc, many, many years ago. But I've gone to NP's ever since and every one I've been to has been exceptionally good. Caring, competent, just downright superior practitioners. Will they replace docs? Heck no, when I'm going for my total hip relacement I want a surgeon! But I wouldn't mind seeing an NP for follow-up.

    Maybe I'll do a study myself. Find a way to make it statistically bombproof and see what the answers really are. Everyone needs a thesis right?

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