An article appeared today in the New York Times as a followup to a bill passed in New York granting nurse practitioners the right to provide primary care without the oversight of a physician. The authors of the bill state "mandatory collaboration with a physician no longer serves a clinical purpose and reduces much-needed access to primary care". The need for more primary care providers is due to the shortage of primary-care physicians, the aging boomer population, and the Affordable Care Act.
Although the president of the American Association of Nurse Practitioners feels that the current "hierarchical, physician-centric structure" is not necessary, many physicians disagree citing that the clinical importance of the physician's expertise is being underestimated and that the cost-effectiveness of nurse practitioners is being over-estimated.
Many physicians also feel that "nurse practitioners are worthy professionals and are absolutely essential to patient care. But they are not doctors."
What are your thoughts on this? Where do nurse practitioners fit into the healthcare hierarchy?
We have resorted to the conspiracy theory response to refute the data? Do you think the landmark study, published in the JAMA, was pushed through with flawed data by the uber powerful nursing interest groups? We are talking about the AMA which dwarfs all the nursing interest groups combined.
So if the data is flawed, please cite the studies that have been published refuting the data.
Those "like nothing" endpoints you listed (and the JAMA study used the SF-36) are responsible for how much cost and morbidity in the US?
Let me guess, premed or M1?
I didn't say the data was flawed. I said the STUDY was flawed with real limitations. Outcomes are more than just numbers like BP, HgA1C, and cholesterol levels over a 6 month to 1 year period. The human body is more than altering a bunch of numbers.
Nice to see that you've now moved on to the next, now that I directly refuted you with 50% of NPs failing their own certification exam.
I didn't say the data was flawed. I said the STUDY was flawed with real limitations. Outcomes are more than just numbers like BP, HgA1C, and cholesterol levels over a 6 month to 1 year period. The human body is more than altering a bunch of numbers.
Nice to see that you've now moved on to the next, now that I directly refuted you with 50% of NPs failing their own certification exam.
And no, neither premed nor M1. Medical Doctor.
The study was flawed in what way? You can say it over and over again but that does not mean it's fact. If the study is flawed, why haven't the flaws been addressed and the true results demonstrated. These results have been repeated over and over using a myriad of outcome markers, both objective and subjective.
The outcomes of the study were measured using several key outcomes that relate to significant morbidity and mortality in this country and are considered quality measures. Additionally the SF-36 was utilized which is the gold standard in medical outcomes having nearly 5,000 publications over thirty years prior to it being replaced with the v2 form.
Now, is every study that has been done thus far flawed?
The study was flawed in what way? You can say it over and over again but that does not mean it's fact. If the study is flawed, why haven't the flaws been addressed and the true results demonstrated. These results have been repeated over and over using a myriad of outcome markers, both objective and subjective.
The outcomes of the study were measured using several key outcomes that relate to significant morbidity and mortality in this country and are considered quality measures. Additionally the SF-36 was utilized which is the gold standard in medical outcomes having nearly 5,000 publications over thirty years prior to it being replaced with the v2 form.
Now, is every study that has been done thus far flawed?
You can say that the study is valid over and over again but that does not mean it's fact. The flaws of the study ARE being addressed. For example, right here, right now.
The outcomes of these studies are determined using statistics like A1c and SBP, which are IMPORTANT OUTCOMES, but DO NOT determine one's ability to be an independent provider. Someone could take a three week course and learn to manage a patient's chronic HTN. That does not mean they should be given the right to practice independently. It is a humongous leap of faith to say that because NPs are able to effectively manage blood pressure that they are totally competent providers for all medical conditions.
I would love to discuss specific studies if you feel that they are not flawed, but all of the studies I have seen cited so far are flawed in at least one of the following ways:
1. Extreme conflict of interests
2. Longitudinally insufficient (Not enough time to observe long-term outcome)
3. Results of study concluded from unrelated outcomes
Another common topic brought up in the debate is that PCPs will just refer patients to specialists if they don't know how to handle the patient's condition, and the argument is that NPs would do the exact same thing. The problem is that NPs don't have the expansive education of physicians that allows them to catch the extremely rare condition that a physician is more likely to notice. The problem isn't that NPs can't refer patients, the problem is that they just won't know when to do that. Now, is that going to happen often? Absolutely not. The expertise of a physician may allow them to catch one rare case in 100 that a nurse won't catch. Obviously this is a hypothetical scenario, but that would result in nurses catching 99% of the cases that need referrals. Statistically, this looks pretty good. As a society though, we'll just have to be okay with the fact that the one patient out of 100 with the rare disease will fall through the cracks.
You can say that the study is valid over and over again but that does not mean it's fact. The flaws of the study ARE being addressed. For example, right here, right now.
The outcomes of these studies are determined using statistics like A1c and SBP, which are IMPORTANT OUTCOMES, but DO NOT determine one's ability to be an independent provider. Someone could take a three week course and learn to manage a patient's chronic HTN. That does not mean they should be given the right to practice independently. It is a humongous leap of faith to say that because NPs are able to effectively manage blood pressure that they are totally competent providers for all medical conditions.
I would love to discuss specific studies if you feel that they are not flawed, but all of the studies I have seen cited so far are flawed in at least one of the following ways:
1. Extreme conflict of interests
2. Longitudinally insufficient (Not enough time to observe long-term outcome)
3. Results of study concluded from unrelated outcomes
Another common topic brought up in the debate is that PCPs will just refer patients to specialists if they don't know how to handle the patient's condition, and the argument is that NPs would do the exact same thing. The problem is that NPs don't have the expansive education of physicians that allows them to catch the extremely rare condition that a physician is more likely to notice. The problem isn't that NPs can't refer patients, the problem is that they just won't know when to do that. Now, is that going to happen often? Absolutely not. The expertise of a physician may allow them to catch one rare case in 100 that a nurse won't catch. Obviously this is a hypothetical scenario, but that would result in nurses catching 99% of the cases that need referrals. Statistically, this looks pretty good. As a society though, we'll just have to be okay with the fact that the one patient out of 100 with the rare disease will fall through the cracks.
I feel like you are wasting your time here. These people will never get that they don't know what they don't know. A physician (D.O.) that I work with used to be a NP and she told me that she used to believe the same nonsense spouting by many in this thread when she was a NP until she went to med school. How the heck someone thinks a FNP is just as qualified as primary care physician (IM/FM/OBGYN/PEDs) is beyond me.
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
So those arguing independence shouldn't happen...can you show a study or something factual that proves bad outcomes? The nurses here have provided studies showing positive outcomes and all we get back is "that study is flawed" and "you seen educated enough". Show us proof that independent practice is bad for patients.
You can say that the study is valid over and over again but that does not mean it's fact. The flaws of the study ARE being addressed. For example, right here, right now.
The "flaws" of well-powered peer-reviewed studies published in major medical journals are being "addressed" via the (clearly) biased debate on the internet. How about they get addressed via research? You can honestly state that your opinion is closer to fact than the reports of more than a half dozen major studies? I don't consider many things "facts" because everything can change, but I do consider things with a substantial body of evidence supporting to be fairly close.
The outcomes of these studies are determined using statistics like A1c and SBP, which are IMPORTANT OUTCOMES, but DO NOT determine one's ability to be an independent provider. Someone could take a three week course and learn to manage a patient's chronic HTN. That does not mean they should be given the right to practice independently. It is a humongous leap of faith to say that because NPs are able to effectively manage blood pressure that they are totally competent providers for all medical conditions.
You honestly think that HTN can be effectively managed after a three week course? How long have you been in primary practice? It is one of many objective indicators of wellness; do you disagree? What do you think the impact would be to this country's healthcare system if primary care completely eliminated the complications of diabetes, hypertension, dyslipidemia, and obesity?
I would love to discuss specific studies if you feel that they are not flawed, but all of the studies I have seen cited so far are flawed in at least one of the following ways:
1. Extreme conflict of interests
2. Longitudinally insufficient (Not enough time to observe long-term outcome)
3. Results of study concluded from unrelated outcomes
If there is "extreme conflict of interest" then please point to the evidence of it. One would think, that the JAMA would be rather hesitant to publish the study if there were major concerns about conflict of interest. If this was a nursing journal....well I would understand readers being a tad more skeptical.
Would you say 3 years better than 6-12 months? That follow-up study was also published and the results were similar. It would be wonderful to have 10, 20, 40 year studies.
Another common topic brought up in the debate is that PCPs will just refer patients to specialists if they don't know how to handle the patient's condition, and the argument is that NPs would do the exact same thing. The problem is that NPs don't have the expansive education of physicians that allows them to catch the extremely rare condition that a physician is more likely to notice. The problem isn't that NPs can't refer patients, the problem is that they just won't know when to do that. Now, is that going to happen often? Absolutely not. The expertise of a physician may allow them to catch one rare case in 100 that a nurse won't catch. Obviously this is a hypothetical scenario, but that would result in nurses catching 99% of the cases that need referrals. Statistically, this looks pretty good. As a society though, we'll just have to be okay with the fact that the one patient out of 100 with the rare disease will fall through the cracks.
Can you cite your evidence on those statistics of 1/100 being missed by NPs over MD/DOs?
And lets be honest, if you are a practicing primary care provider, I am sure you know that many more than one patient out of a hundred "falls through the cracks" no matter what provider they see.
The "flaws" of well-powered peer-reviewed studies published in major medical journals are being "addressed" via the (clearly) biased debate on the internet. How about they get addressed via research? You can honestly state that your opinion is closer to fact than the reports of more than a half dozen major studies? I don't consider many things "facts" because everything can change, but I do consider things with a substantial body of evidence supporting to be fairly close.
You're right - this debate is clearly biased. There have only been a handful of dissenting voices on this forum; the overwhelming majority of participants are staunchly in favor of complete autonomy for nurses. I was just stating this forum as an example among many, the most important of which are the state legislatures.
Something that is probably more semantics than anything, but is nonetheless important to note, is that I don't disagree with the findings of the studies. I disagree with some people that take the result of a study that shows NPs can manage a patient's BP as well as a physician over a short period of time and then conclude that NPs provide equal care, and should therefore be able to practice independently. That NPs can manage BP equally or can evoke equal patient satisfaction is a fact, and obviously I agree with that. I don't agree with the opinion of some that those outcomes therefore make NPs qualified to practice medicine.
You honestly think that HTN can be effectively managed after a three week course? How long have you been in primary practice? It is one of many objective indicators of wellness; do you disagree? What do you think the impact would be to this country's healthcare system if primary care completely eliminated the complications of diabetes, hypertension, dyslipidemia, and obesity?
HTN is an objective indicator of wellness, I agree. I absolutely agree that the consequences of unmanaged HTN or DM, for example, would be devastating. I hope you don't misunderstand me - these are all very important aspects of patient care that definitely need great management. I think nurses do a fabulous job of managing these conditions in patients that suffer from them chronically. I don't think that nurses' success in managing these conditions qualifies them to be independent practitioners.
If there is "extreme conflict of interest" then please point to the evidence of it. One would think, that the JAMA would be rather hesitant to publish the study if there were major concerns about conflict of interest. If this was a nursing journal....well I would understand readers being a tad more skeptical.
The conflict of interest is that many of these studies are funded by nursing organizations. I compare it to the scenario of a study that examines the efficacy of a new drug. If the study was funded by the company that produces the drug, it would be a conflict of interest. Likewise, nursing organizations have a stake in the outcome of the study.
Would you say 3 years better than 6-12 months? That follow-up study was also published and the results were similar. It would be wonderful to have 10, 20, 40 year studies.
I absolutely agree with you - it would be wonderful to have studies of that length. Unfortunately, those studies don't exist and would probably be very expensive to conduct. I think a 3 year study is more convincing than a 12 month study, but it is still not enough time for the patients to experience significant problems with missed diagnoses or comorbidities, or poor management. If a patient goes 3 years with poorly managed hyperglycemia, will you see problems? Yes, very likely. If a patient goes 3 years with an undiagnosed and subtle comorbid disease, will you see problems? Not necessarily. The issue is that many times these conditions can progress asymptomatically over a long period of time and will go unnoticed until it is too late to treat them, either resulting in mortality or unnecessary permanent disability.
Can you cite your evidence on those statistics of 1/100 being missed by NPs over MD/DOs?
The 1/100 was merely used as a hypothetical number, which I stated. That is one of the disadvantages I believe that nurses face, precisely because they specialize so early in their training. A physician spends 4 years of medical school studying every type of disease, and material from every specialty. Although they won't be experts in any field except their own, they have a significantly larger amount of experience with these other conditions than would a nurse. I want to note here that this has nothing to do with how intelligent a nurse is - I'm sure there are many nurses that are smarter than physicians. This is merely because physicians were exposed to the material in school while the nurses were out treating patients in their specialty.
And lets be honest, if you are a practicing primary care provider, I am sure you know that many more than one patient out of a hundred "falls through the cracks" no matter what provider they see.
I absolutely agree with you. I would argue, though, that these patients that fall through the cracks warrant more training, not less, so that we are more likely to be able to provide the care they need, when they need it.
I want a physician to treat me. I use to think otherwise but I just don't feel 2 years of education is enough. Sorry. And fast tracking any major to become a np within 3 years? Zero experience as a nurse. It's pathetic. Nursing is undermining itself.
I want a physician to treat me. I use to think otherwise but I just don't feel 2 years of education is enough. Sorry. And fast tracking any major to become a np within 3 years? Zero experience as a nurse. It's pathetic. Nursing is undermining itself.
You can be a physician in 3 years now, also without any nursing or other healthcare exp, just FYI.
You're right - this debate is clearly biased. There have only been a handful of dissenting voices on this forum; the overwhelming majority of participants are staunchly in favor of complete autonomy for nurses. I was just stating this forum as an example among many, the most important of which are the state legislatures.
As I said before, I think these types of discussions are important ones. I am glad there are some crossovers here discussing the issue and I think it has been a good debate (from most). Sadly, even at the state level (as least from my state NP association) there is a lack of interactive interdisciplinary dialogue on the topic.
Personally I have no desire to work "autonomously". I use the word in quotes because, for me, "autonomous" practice would me owning a business/practice, which I have no desire to do (and not have my ICU notes cosigned). I work with two physicians in a large practice that are both well over retirement age than have searched for another MD for the past 6 years with no luck. If they retire what happens to their practice? I am out of a job and all the patients are on their own to find a new PCP, which is limited in our area despite being a medical mecca. The other option is we keep the practice (the NPs/PAs) and pay $10-15k a quarter to have a physician "review" charts for an hour. Are any of these good options?
Something that is probably more semantics than anything, but is nonetheless important to note, is that I don't disagree with the findings of the studies. I disagree with some people that take the result of a study that shows NPs can manage a patient's BP as well as a physician over a short period of time and then conclude that NPs provide equal care, and should therefore be able to practice independently. That NPs can manage BP equally or can evoke equal patient satisfaction is a fact, and obviously I agree with that. I don't agree with the opinion of some that those outcomes therefore make NPs qualified to practice medicine.
It is a matter of semantics in some manner but it is also a bit of a precarious positions for most physicians: they want to acknowledge the quality and cost effective care NPs provide because they want to utilize NPs to make their practice money (I don't think anyone will argue that NPs provide practices with excellent ROI) but they don't want that quality and cost effective care to be independent of them because they lose that benefit. If the studies were on BP alone that's one thing, but the studies have demonstrated similar results across nearly every objective quality measure from BP to A1C to hospital readmission rates to SF-36 results to COPD management and so forth. These are major chronic conditions at big costs to the healthcare system as well as pateint morbidity and mortality.
HTN is an objective indicator of wellness, I agree. I absolutely agree that the consequences of unmanaged HTN or DM, for example, would be devastating. I hope you don't misunderstand me - these are all very important aspects of patient care that definitely need great management. I think nurses do a fabulous job of managing these conditions in patients that suffer from them chronically. I don't think that nurses' success in managing these conditions qualifies them to be independent practitioners.
I am sure we actually agree on 99% of diagnosis and treatment in primary care, though in this debate no one wants to admit that.
I am curious, if NPs do a fabulous job of managing chronic conditions studied (HTN, HL, DM, COPD, obesity, asthma, depression, anxiety, arthritis, preventative medicine) how does that not equate to the ability to provide fabulous primary care. These diagnosis make up the vast majority of primary care and chronic disease management and are directly responsible for the vast amount of complications our healthcare system faces. What about this does not mean quality primary care?
The conflict of interest is that many of these studies are funded by nursing organizations. I compare it to the scenario of a study that examines the efficacy of a new drug. If the study was funded by the company that produces the drug, it would be a conflict of interest. Likewise, nursing organizations have a stake in the outcome of the study.
Wait, who funds clinical trials for medications being approved by the FDA?
I absolutely agree with you - it would be wonderful to have studies of that length. Unfortunately, those studies don't exist and would probably be very expensive to conduct. I think a 3 year study is more convincing than a 12 month study, but it is still not enough time for the patients to experience significant problems with missed diagnoses or comorbidities, or poor management. If a patient goes 3 years with poorly managed hyperglycemia, will you see problems? Yes, very likely. If a patient goes 3 years with an undiagnosed and subtle comorbid disease, will you see problems? Not necessarily. The issue is that many times these conditions can progress asymptomatically over a long period of time and will go unnoticed until it is too late to treat them, either resulting in mortality or unnecessary permanent disability.
No matter how good you are you have missed a diagnosis, I am sure I have and I am willing to bet you are sure you have to. It, unfortunately, happens. I find that spending more time with patients than my physician counterparts that I discover many of them.
It is difficult to comment about this because those studies (to my knowledge) just haven't been done. I have never seen any data that links NPs to more missed diagnoses than physicians. Do you think there is an increased in missed diagnoses when a provider sees 16 patients a day compared to seeing 20 patients a day? I would venture to guess there is, but I don't' see physicians arguing that they should see no more than "x" patients a day.
The 1/100 was merely used as a hypothetical number, which I stated. That is one of the disadvantages I believe that nurses face, precisely because they specialize so early in their training. A physician spends 4 years of medical school studying every type of disease, and material from every specialty. Although they won't be experts in any field except their own, they have a significantly larger amount of experience with these other conditions than would a nurse. I want to note here that this has nothing to do with how intelligent a nurse is - I'm sure there are many nurses that are smarter than physicians. This is merely because physicians were exposed to the material in school while the nurses were out treating patients in their specialty.
That education and exposure is impressive, I don't think anyone (seriously) debates that. The debate for me is whether that education and exposure provides primary care patients with better outcomes or a bigger bill.
And for the record, most practicing NPs do no work in a specialty (from that last set of data I saw) and for the most part are educated and trained as generalists, save perhaps for psych NPs.
Do you think the dermatologist who has been in practice for 30 years could walk into a internal medicine clinic and provide quality IM care?
I absolutely agree with you. I would argue, though, that these patients that fall through the cracks warrant more training, not less, so that we are more likely to be able to provide the care they need, when they need it.
I would argue that the patients that fall through the cracks warrant more time spent with a provider and better access to healthcare.
I didn't say the data was flawed. I said the STUDY was flawed with real limitations. Outcomes are more than just numbers like BP, HgA1C, and cholesterol levels over a 6 month to 1 year period. The human body is more than altering a bunch of numbers.
Nice to see that you've now moved on to the next, now that I directly refuted you with 50% of NPs failing their own certification exam.
And no, neither premed nor M1. Medical Doctor.
You never did answer then why doesn't the AMA come out with their own studies showing superiority of physician training?
The data nor those studies are flawed. The beliefs that some physicians have in their own superiority is the only flawed subject in the debate over whether APNs/NPs should be able to provide independent care.
I will look back through my posts, but I don't think I ever suggested NPs have a 50% pass rate on their boards. I was referring to the comments on NPs taking the USLME.
I feel like you are wasting your time here. These people will never get that they don't know what they don't know. A physician (D.O.) that I work with used to be a NP and she told me that she used to believe the same nonsense spouting by many in this thread when she was a NP until she went to med school. How the heck someone thinks a FNP is just as qualified as primary care physician (IM/FM/OBGYN/PEDs) is beyond me.
You cannot cite what it is that NPs do not know. You refute every scientific study done showing that NPs provide quality care independent that is comparable to physician care, and no medical society has been able to produce a study to refute any of these findings, and yet it is the APNs that don't know we don't know. I know someone must have supersize ego to believe that in the face of overwhelming scientific evidence.
Having worked with physicians for over 16 years, trained with physicians, and went to some of the same medical school classes as physicians I would like to know where this secret physician only knowledge class is taught in medical school. I know for fact that when physicians need to look up something they utilize the same texts/reference materials as the rest of us.
"Nurse practitioners (NPs) are high quality health care providers who practice in primary care, ambulatory, acute care,specialty care, and long-term care. They are registered nurses prepared with specialized advanced education and clinicalcompetency to provide health and medical care for diverse populations in a variety of settings. A graduate degree isrequired for entry-level practice. The NP role was created in 1965 and over 45 years of research consistently supports theexcellent outcomes and high quality of care provided by NPs. The body of evidence supports that the quality of NP careis at least equivalent to that of physician care. This paper provides a summary of a number of important research reportssupporting the NP." https://www.aanp.org/images/documents/publications/qualityofpractice.pdf
Avorn, J., Everitt, D.E., & Baker, M.W. (1991). The neglected medical history and therapeutic choices for abdominalpain. 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 regardingepigastric pain in a patient with endoscopic findings of diffuse gastritis. They were able to request additional informationbefore recommending treatment. Adequate history-taking resulted in identifying use of aspirin, coffee, cigarettes, andalcohol, paired with psychosocial stress. Compared to NPs, physicians were more likely to prescribe without seeking relevanthistory. NPs, in contrast, asked more questions and were less likely to recommend prescription medication.
Bakerjian, D. (2008). Care of nursing home residents by advanced practice nurses: A review of the literature.Research in Gerontological Nursing, 1(3), 177-185.
Bakerjian conducted and extensive review of the literature, particularly of NP-led care. She found that long-term carepatients managed by NPs were less likely to have geriatric syndromes such as falls, UTIs, pressure ulcers, etc. They also hadimproved functional status, as well as better managed chronic conditions.
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 thatNP outcomes were equivalent to or greater than those of physicians. NP patients had higher levels of compliance withrecommendations in studies where provider assignments were randomized and when other means to control patientrisks were used. Patient satisfaction and resolution of pathological conditions were greatest for NPs. The NP and physicianoutcomes were equivalent on all other outcomes.
Congressional Budget Office. (1979). Physician extenders: Their current and future role in medical care delivery.Washington, D.C.: US Government Printing Office.
As early as 1979, the Congressional Budget Office reviewed findings of the numerous studies of NP performance in a varietyof 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.
A study of 199 patients randomly assigned to emergency NP-led care or physician-led care in the U.K. demonstrated thehighest level of satisfaction and clinical documentation for NP care. The outcomes of recovery time, symptom level, missedwork, unplanned follow-up, and missed injuries were comparable between the two groups.
Ettner, S.L., Kotlerman, J., Abdelmonem, A., Vazirani, S., Hays, R.D., Shapiro, M., et al. (2006). An alternative approachto 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 1207 patients in an academic medical center were randomized to eitherstandard treatment or to a physician-NP model.
Horrocks, S., Anderson, E., Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primarycare can provide equivalent care to doctors. British Medical Journal, 324, 819-823.
A systematic review of 11 randomized clinical trials and 23 observational studies identified data on outcomes of patientsatisfaction, health status, cost, and/or process of care. Patient satisfaction was highest for patients seen by NPs. The healthstatus data and quality of care indicators were too heterogeneous to allow for meta-analysis, although qualitative
Administration: PO Box 12846 * Austin, TX 78711 * 512-442-4262 * Email: [email protected] * Website: http://www.aanp.orgOffice of Health Policy: 225 Reinekers Lane, Suite 525 * Alexandria, VA 22314 * 703-740-2529 * Email: [email protected]
comparisons of the results reported showed comparable outcomes between NPs and physicians. NPs offered moreadvice/information, had more complete documentation, and had better communication skills than physicians. NPs spentlonger time with their patients and performed a greater number of investigations than did physicians. No differenceswere detected in health status, prescriptions, return visits, or referrals. Equivalency in appropriateness of studies andinterpretations of x-rays were identified.
Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2006). Substitution of doctors by nursesin 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 fornurses and physicians. The satisfaction level was higher for nurses. Studies included a range of care delivery models, withnurses 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 bynurse 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 reportincluding two years of follow-up data, confirming continued comparable outcomes for the two groups of patients. Nodifferences were identified in health status, physiologic measures, satisfaction, or use of specialist, emergency room, orinpatient services. Patients assigned to physicians had more primary care visits than those assigned to NPs.
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 caredirected towards wellness, health promotion, disease prevention, and health education than PAs, regardless of the settingtype. In contrast , PAs were more likely to provide acute problem management and to involve another person, such as asupport staff person or a physician.
Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y., Cleary, P.D., et al. (2000). Primary care outcomes
in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American MedicalAssociation, 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 forprimary care between 1995 and 1997, using patient interviews and health services utilization data. Comparable outcomeswere 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 atboth 6 and 12 months and patient satisfaction was equivalent following the initial visit. The only exception was that at sixmonths, physicians rated higher on one component (provider attributes) of the satisfaction scale.
Newhouse, R. et al (2011). Advanced practice nurse outcomes 1999-2008: A systematic review. Nursing Economic$,29 (5), 1-22.
The outcomes of NP care were examined through a systematic review of 37 published studies, most of which compared
NP outcomes with those of physicians. Outcomes included measures such as patient satisfaction, patient perceived healthstatus, functional status, hospitalizations, ED visits, and bio-markers such as blood glucose, serum lipids, blood pressure. Theauthors conclude that NP patient outcomes are comparable to those of physicians.
Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified nurse midwives: Apolicy analysis. Washington D.C.: US Government Printing Office.
The Office of Technology Assessment reviewed studies comparing NP and physician practice, concluding that, "NPs appearto have better communication, counseling, and interviewing skills than physicians have." (p. 19) and that malpracticepremiums and rates supported patient satisfaction with NP care, pointing out that successful malpractice rates against NPsremained extremely rare.
Ohman-Strickland, P.A., Orzano, A.J., Hudson, S.V., Solberg, L.I., DiCiccio-Bloom, B., O'Malley, D., et al. (2008). Qualityof diabetes care in family medicine practices: Influence of nurse-practitioners and physician's assistants. Annals ofFamily Medicine, 6(1), 14-22.
The authors conducted a cross-sectional study of 46 practices, measuring adherence to ADA guidelines. They reported
that practices with NPs were more likely to perform better on quality measures including appropriate measurement ofglycosylated hemoglobin, lips, and microalbumin levels and were more likely to be at target for lipid levels.
ScienceWiz
9 Posts
I didn't say the data was flawed. I said the STUDY was flawed with real limitations. Outcomes are more than just numbers like BP, HgA1C, and cholesterol levels over a 6 month to 1 year period. The human body is more than altering a bunch of numbers.
Nice to see that you've now moved on to the next, now that I directly refuted you with 50% of NPs failing their own certification exam.
And no, neither premed nor M1. Medical Doctor.