• 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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  • Expanding the primary care supply

    There really isn’t much need for further comment on the idea of enabling nurse practitioners and other non-physicians to practice at the top of their training and to help meet the demand for primary care. It was the lead subject in yesterday’s Wonkbook. So, you could go read that. Just over a week ago Mike Miesen reported on the fate of California’s nurse practitioner scope of practice legislation for Project Millennial, where he has covered the issue before (and before that). So, you could go read that too.

    Suffice it to say, this is a well-worn idea, but a good one. Even if one believes that physicians would provide higher quality or safer care (and one must ignore some evidence to hold these views), primary care physicians are in short supply in some regions. Health reform will accelerate the strain on that supply.

    In light of these facts, for what reasonable, patient-centered reason should other health care professionals not practice at the top of their education and step into the breech? Is the argument that it would be better to see no health care professional or wait a long time to do so than to see a nurse practitioner for primary care? It hardly seems reasonable.

    In any case, Victor Fuchs agrees. In a new JAMA viewpoint, he wrote,

    The demand for primary care is strong and likely to grow stronger. It is, however, unwise to think that the demand could or should be met by an increase in the supply of primary care physicians. […] With proper organization, the majority of first-contact primary care could be met by an increase in the supply of nurse practitioners, physician assistants, and medical aides working under a “leader of a primary care team” who has been specially trained for such a role. Moreover, the leader’s compensation could and should be comparable with that of other specialists. Such leaders could, where appropriate, subspecialize into pediatric, adult, and geriatric care.

    How is this not a good idea? At the very least, why is it not worth trying in regions that are in clear need of more primary care? I acknowledge that some physicians may view this as an encroachment of their turf, unwanted competition. Nevertheless, for the good of patients, and the country, docs need to get out — or be pushed out — of the way on this one.


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  • Will mid-level practitioners steal our business?

    I’ve often written on the shortage of physicians in the US. Recently, Sarah Kliff posted on the upcoming debacle that might result if we don’t soon increase the numbers of primary care docs. One thing that might help is if we employed more mid-level practitioners, like nurse practitioners. This is opposed by a number of physician groups:

    In its 2010 report, “The future of nursing: leading change, advancing health,” the Institute of Medicine recommends the removal of scope of practice (SOP) barriers for advanced practice registered nurses (APRNs) such that they can “practice to the full extent of their education and training” (IOM, S-4). Currently, only 16 states and the District of Columbia (DC) allow APRNs to practice independently of physicians…

    In response to the IOM recommendation, the American Medical Association and the American Academy of Family Physicians, among others, have expressed their opposition, pointing out that physicians have more extensive education and arguing that nurses are not substitutable with primary care physicians. While the question of whether there are economic interests that might be negatively impacted by reforms is rarely discussed openly, the perceived impact of reform, particularly on primary care physicians, undoubtedly has and will continue to play a role in whether and to what extent SOP laws are reformed.

    So it would be great if someone actually studied whether such laws impact how much docs might make. Well, someone did:

    In this analysis, we compare the earnings of primary care physicians (family and general practice physicians and general pediatricians) to the earnings of surgeons. We assume that because primary care physicians’ practice overlaps with that of APRNs, in particular nurse practitioners, whereas surgeons’ practices do not, any effect on earnings from increased nursing autonomy would appear among the former two groups without effecting surgeons’ incomes. It is important to note that while a small number of APRNs may be certified as first assistants in surgery, this is not an area of independent APRN practice and, as such, would not be affected by variations in SOP laws.

    So what did they find? The average earnings for FPs and GPs in states where there were no restrictions on mid-level practitioners (full SOP) were $79.36 per hour, compared to $81.15 in states with more restrictions. The difference was not statistically significant. The average earnings for primary care pediatricians in full SOP/no restriction states were $83.94 per hour, compared to $78.43 per hour in more restrictive states. Again, that wasn’t significantly different. Surgeons earned $107.23 per hour in no restriction states, versus$103.85 on more restrictive states (again, no difference). So bottom line – there was no difference. Allowing more mid-level practitioners to practice freely and independently was not associated with physicians earning less.

    In the interest of full disclosure, I’m married to a nurse practitioner. So I may be biased in my assessment that she’s amazingly talented. But for those physicians who are worried that increasing the ability of mid-level practitioners to work independently might negatively impact their income, that doesn’t necessarily seem to be the case.

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