• If physicians outperform nurses at primary care, the evidence doesn’t show it

    The following is a guest post by Mike Miesen, a Business Strategy Analyst at a New York City-based global health social enterprise. Find him on Twitter: @MikeMiesen.

    Cardiologist Dr. Sandeep Jauhar recently took to the op-ed page of the New York Times to argue that legislation to broaden the scope of practice for New York nurse practitioners is a mistake:

    Though well intentioned, such proposals underestimate the clinical importance of physicians’ expertise and overestimate the cost-effectiveness of nurse practitioners.

    The first contention is rebutted by a vast body of research on this question. The second is based on a cherry-picked, underpowered study that doesn’t directly support the argument.

    To argue that nurse practitioners (NPs) are unable to provide the same quality of care as physicians, Dr. Jauhar marshals this evidence:

    When I was doing my internship, 15 years ago, a fellow intern told me about a patient she had seen in the clinic whose voice was hoarse. She had no idea what was wrong with him, but her primary-care instructor, on a routine pass by, immediately diagnosed goiter, an enlargement of the thyroid gland.

    It’s telling that he uses an anecdote to make his case; he would be wholly unable to do so with data.

    Simply put: the preponderance of empirical evidence indicates that, compared to physicians, NPs provide as good – if not better – quality of care. As I’ve written previously, patients are often more satisfied with NP care – and sometimes even prefer it.

    The Institute of Medicine is unambiguously clear about this:

    No studies suggest that APRNs [Advanced Practice Registered Nurse]  are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.

    Even the National Governor’s Association – in 2012, hardly a bastion of left-wing sentiment – concluded:

    None of the studies in NGA’s  [National Governor’s Association] literature review raise concerns about the quality of care offered by NPs. Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcomes measures. Moreover, the studies suggest that NPs may provide improved access to care.

    When NPs provide frontline primary care, patient safety is not at risk. Full stop.

    Dr. Jauhar’s second contention is that NPs aren’t as cheap as people think. To back it up, he cites a 1999 study published in Effective Clinical Practice:

    …primary-care patients assigned to nurse practitioners underwent more ultrasounds, CT scans and M.R.I. scans than did patients assigned to physicians. The nurse practitioners’ patients also had 25 percent more specialty visits and 41 percent more hospital admissions.

    Some context helps: the study looks at a set of utilization measures and health outcomes for patients at Baltimore Veterans Affairs Medical Center who were assigned to either an attending physician, resident physician, or NP.  But there is a severe, methodological flaw: in some cases, an NP chose which group each patient was assigned to! So, this was hardly a pristine, randomized experiment. Also, it’s just one study, and one within a system– the VA – that’s quite a bit different than the rest of the US health care system. One should never draw conclusions from just one study, and certainly not one with clear flaws and threats to generality.

    But you can set those limitations aside, because the figures Dr. Jauhar cites on specialty visits and hospital admissions aren’t even statistically significant (only ophthalmology visits were). Dr. Jauhur argues that NPs’ greater use of diagnostic scans is “to compensate for a lack of training,” which could be true, or, as the study’s authors hypothesize, it could also be due to physicians asking for the extra tests to be done or specialists ordering the extra tests. In any case, the study doesn’t shine any light on the cause.

    And tellingly, the study does not actually investigate the costs incurred by NPs or physicians.

    Dr. Jauhar is right: there isn’t much solid research investigating the cost of NP-led care compared to physician-led care in America. But the research that exists lends credence to the assertion that NP-led care is often less costly than physician-led care (these aren’t unbiased sources, of course, but decent reviews of the literature nonetheless).

    Where does that leave us? Compared to physicians, NPs provide a similar, or better, quality of care; are a more agile and flexible workforce to deploy, taking a fraction of the time to train; earn less; and the preponderance of evidence indicates they are able to provide care more cheaply.

    Given all this, it’s very hard to view arguments to the contrary as anything but willful ignorance of evidence. And it’s very hard to discount self-interested motivations to make those arguments.

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