Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 1 Effectiveness of Nurse Practitioners in Primary and Specialty Care Maria-Idalia O. Lens. RN, PHN, MSN, NP-C University of San Francisco Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 2 Effectiveness of Nurse Practitioners in Primary and Specialty Care History of the Nurse Practitioner The first nurse practitioner (NP) program was at the University of Colorado in1965. It was created to help promote health and prevent disease in the pediatric population (Bishop, 2009). By 1970 graduate programs were being introduced for nurse practitioners (NP’s) and in 1979 the National League of Nursing published a position paper for NP’s, stating that NP’s needed to have a master’s in nursing to practice (Bishop, 2009). Recently, the American Association of Colleges of Nursing (AACN) published a position paper that advance practices nurses should have a doctorate in nursing to practice (AACN, 2004). The education of NP’s has evolved over the years, as well as the setting in which they work in. The majority of NP’s have worked mainly in primary care, but have transcended into other specialty areas such as, psychiatry, palliative care, cardiology, and oncology (National League for Nursing, Wheeler & Haber, 2004). According to the American Academy of Nurse Practitioners (AANP) database, the majority of NP’s work in family practice (49.2%) (AANP, 2009). There has been an abundance of research done on NP’s that has validated their quality, cost-effectiveness, satisfaction, and competencies in primary care and specialty care (Landro, 2008). The Primary and Specialty Physician Shortage In the 1981, the Graduate Medical Education National Advisory Committee (GMENAC) predicted a surplus of specialty physicians (Cooper, 2002). Based on this prediction the Bureau of Health Professions and the Council on Graduate Medical Education (COGME), proposed a 20% reduction in first year residents and increase the ratio of generalists to specialists by 50% (Cooper, 2002). Many of these proposals were endorsed by professional organizations. However, now it is evident that there is no surplus (Cooper, 2002). These predictions created Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 3 many predicaments and the Balanced Budget Act of 1997 and the Veterans Administration decreased support in specialty training (Cooper, 2002). Many medical schools felt compelled to have their students choose primary care and as result specialty care weakened (Cooper, 2002). In 2002, it was evident that the methodologies used during the previous predictions were inaccurate (Cooper, 2002). Other factors contributing to physician shortages are a decrease in work hours for physicians, mid-level providers providing care, and the growth of the United States population (Cooper, 2002). The current trend is moving primary care away from physicians to NP’s or physician assistants (PA’s) to outpatient and inpatients settings (Cooper, 2002). More insurance and health plans are covering care provided by mid-level providers (Cooper, 2002). Even though there is a shortage of primary care physicians, however, primary care doctors are being recruited in specialty areas because there is a shortage there as well (Cooper, 2002). The American Society of Clinical Oncology in 2007 released a statement that there will be a shortage of oncologists by 2020 (Bishop, 2009). The demand in oncology will grow quicker than oncologists (Bishop, 2009). The NP’s competencies in oncology can improve patient care, increase access, and manage patients in oncology as the shortage is expected (Bishop, 2009). The role of the oncology NP is increasing as patients with cancer are now treated as a chronic disease not an acute one (Young, 2005). Waiting rooms for oncologists are inundated with newly diagnosed cancer patients from the aging population (Young, 2005). Patients are living longer through the advances in medicine, that many treatments can be done in outpatient settings (Young, 2005). Many NP’s in oncology who have a family medicine clinical background on managing multiple comorbities are familiar to the NP, such as diabetes, hypertension, and hypercholesteremia will increase familiarity with medications and managing these comorbities Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 4 (Young, 2005). As NP’s continue to increase nationwide at an average of 5,500 annually (AANP, 2009), this can aide as the physician shortage continues (Bishop, 2009). While NP’s continue to work in different areas many institutions will continue to monitor their cost effectiveness, quality, and working models (Landro, 2008). The continued monitoring can help aide the NP’s process and expansion since most of the literature has shown that NP’s provide safe and effective care and increase patient satisfaction and quality care (Horrocks, Anderson, Salisbury, 2002). This review of literature examines how nurse practitioners care has no increase in costs, compares physician care, and works in a community based program. Cost Effectiveness in General Practice Nurse practitioners have been industrialized in the United States (US) for some time, but have recently been adapted in the United Kingdom (UK) (Venning, 2000). NP’s are being used as the first contact in primary care (Venning, 2000). The number of NP’s are increasing and becoming more accessible (Venning, 2000). There have been many randomized controlled trials done in the US and Canada to compare cost effectiveness between NP’ and physicians (Venning, 2000). Many of these studies were conducted at single centers and not multiple sites (Venning, 2000). Since cost effectiveness of NP’s has been studied in the US, cost effectiveness in the UK, was evaluated to confirm findings from other studies to be able to generalize these findings. Venning, Durie, Roland, Roberts, and Leese (2000) studied the cost effectiveness and outcomes, of NP’s compared to physicians in the UK at multiple centers focused on primary care. The aim of the study was to compare the process, outcome, and costs by physicians and NP’s. The researchers enrolled 1292 patients that had either seen an NP or physician; sessions were blocked off so patients would be able to be seen on the same day. Eligibility for the study included patients who dropped in the center on the same day and were able to attend an Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 5 experimental session. The researchers believed it would be easier to recruit patients if they wanted to be seen on the same day because patients would not prefer to see a physician or NP. Once participants meet the eligibility criteria, the receptionist approached them and asked if they would mind if they were randomized to see an NP or physician. Block coding was done so the receptionist would not know whom the participants were seeing. Randomization was broken at the start of the sessions since it was evident whom the participant was seeing. Recruitment stopped once each center obtained sixty participants in each clinician group at each center. Participants were excluded if they were already established patients were too ill, not registered with the practice, had language or reading barriers, and if not accompanied by an adult who was younger than sixteen years of age. The researchers collected data on the NP’s and physicians based on their booked appointments and normal intervals. Each consultation was recorded for details of the history, diagnosis, examination, tests ordered, prescriptions, and referrals. The time of each consultation was recorded through an electronic time stamp, which included the time taken by the NP to get a prescription signed by the physician. Participants completed health status questionnaires before each consultation and two weeks later. After each consult, the participants did a patient satisfaction interview. The researchers coded each of the participant’s diagnosis and prescriptions. All data was double coded, double entered and double verified. For patient satisfaction the data was recorded if half of the measures were reported using the SF-36 scale, which was not described. Costs of the providers were taken from the Netten and costs of prescriptions were retrieved using the British National Formulary. The individual providers depending on the discipline supplied the costs for referrals and investigations. Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 6 After completing the study the researchers found that NP’s and physicians showed no significant differences in regards to costs. The correlation between cost accrued between NP’s and physicians was r= -.04 and a Cohen’s d of -.077. However, differences in practice were seen between NP’s and physicians. NP’s spent more consultation time with patients with a significant p < .001 and a Cohen’s d of .97 with an r= .44 showing a moderate relationship. NP’s were also likely to ask patients to return for a follow up visit with a significant p< .001 and a Cohen’s d of .81 with a small relationship of r= .37. Satisfaction scores showed more satisfaction with NP’s as well with a significant p< .001 and a Cohen’s d of .81 and with small relationship of r=16. Patients seen by NP’s were more likely to return to the clinic compared to patients seen by physicians. The researchers also found that there was no difference in health status at the end of two weeks. All costs were integrated for salaries, prescriptions, referrals, tests, and costs of return visits. No significant differences in costs were seen from care from the NP or physician group, which showed a Cohen’s d of -0.08 with no relationship r= -.03. The researchers found no differences in cost but stated that if NP’s were to order fewer tests and not ask patients to return then there would be a cost difference that would be significant. The results of this study used quantitative methods to measure the differences in costs, return visits, and patient satisfaction between NP’s and physicians. The researchers did not find any differences in cost, which shows how NP’s can provide quality care comparable to a physician. This study demonstrates NP’s giving high quality care through their high satisfaction scores among patients. NP’s spend more face to face time with patients, order more tests, and ask patients to return for follow without accruing more costs. One of the limitations to the study was that NP’s in the UK need physician approval for prescriptions that does not let NP’s to practice independently like in the US. Other limiting factors could be the sample population who sought Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 7 a same day appointment due to increase the numbers in the sample size. NP care is demonstrated in this study how clinical care is similar to a physician and how outcomes of patient care is also similar. This study demonstrates how NP’s give comparable care to a physician as well as an increase in quality by spending more time with patients during consultations and also having higher return visits. If NP care is comparable than NP’s can help with seeing patients in primary care settings to help with the physician shortage. Patient Outcomes and Quality Recent literature has been published about the quality care that has been delivered by NP’s (Lenz, Mundinger, Kane, Hopkins, & Lin, 2004). In 1974 the Burlington research trial found that NP’s gave comparable care similar to physicians in physical, emotional, and social function (Sackett, Spitzer, Gent, M., & Roberts, 1974). In another study no significant differences were found in patient outcomes between NP’s and physicians (Mundinger, 2000). NP’s have also shown to provide more education on nutrition, weight, exercise, and medications for diabetic patients (Lenz, 2002). The researcher hypothesized that there would be no differences between NP and MD patient outcomes (Lenz, et al. 2003). Lenz, Mundinger, Kane, Hopkins, and Lin (2003) studied the outcomes of patients randomly assigned to and NP or physician in primary care after two years from an initial follow- up. The researchers used Donabedian’s model for outcomes and conceptualizations for professionalization. Donabedian’s model provided a more logical structure for education of the providers, patient characteristics, resources available, policies, and expectations (Lenz, et al. 2003). Lenz and et al (2003) studied from a previous population that was studied before during the first phase of this project. A prior study that only observed outcomes at six and 12 months. Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 8 In the initial study participants were recruited from emergency and urgent care in an urban setting. These patients were randomly assigned to primary care for follow-up to see an NP or MD. Patients also had the option to switch providers if they requested it. This time the researchers studied the same outcomes after two years. In this study there were 406 patients completed part two of the study. These participants were recruited through telephone, mail, and home visits. This sample had only seen the provider that had originally been assigned to decrease any bias after participants had switched providers or was seen by more than one provider. The sample studied were mostly Hispanic (92.6%), likely to be diabetic (11.6%), older, hypertensive (37.4%), and on Medicaid (91.1%). The study examined the following research questions: Are there any differences in outcomes of randomly assigned patients to NP’s and MD’s in primary care after two years of their initial practice. Each participant choose the site for data collection: their home, university office, or by phone. Bilingual interviewers obtained the data collection for participants who needed interpretation for the medical outcomes study short form 36 (MOS SF-36) to measure health status (Lenz et al. 2003). A measurement for primary care and patient satisfaction was measured through the Patient Care Assessment Survey (PCAS). These scores ranged from 0-100 that was extrapolated. The researcher reported that the PCAS showed strong reliability and validity but were not reported. Nurse who were bilingual took blood pressure readings, peak flows, drew blood to measure glycosylated hemoglobin. The medical center provided the billing information to the researchers as well. The researchers used various ways to interpret the data: Chi-square, t- tests, and repeated measures for analysis of variance. Only 405 patients participated in this study compared to 1.316 in phase one of the study (Lenz et al. 2003). The results of the study concluded that after two years from the initial visit Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 9 there were similar levels of patient health status, satisfaction, and utilization (Lenz et al 2003). Most of the representative samples showed to have Medicaid were in the physician group. For self reported health status in physical function there was no significant difference (p=. 142) between NP and MD group, which showed a Cohen’s d of .15 and a effect size of r=. 07. Hypertensive patients also showed no difference in outcomes except that both groups were able to lower blood pressure, showing a Cohen’s d of -.15 and an r of -.08 with no correlation or difference with a p=. 38. For patient satisfaction in trust the primary care providers also showed no significant differences with a Cohen’s d of -.05 and an r=-.03 with a p =. 713. This study shows how NP care is comparable to MD care and how there are no differences. This study does have threats to realibility and validity because of the smaller sample size in phase two of the study as compared to phase one. Most of the sample was from the Hispanic population, which is not specific to the rest of the United States unless there is a high Hispanic population increasing language barriers. Sample studied only included participants who have not seen other providers, therefore limiting the analysis of these patients (Lenz et al. 2003). This study did have a sufficient sample as seen through the power analysis done to have a power of .8 and an alpha of .05 to decrease results due to chance. The researchers do address the bias in the article and suggest additional studies to measure on the differences between NP’s and MD’s on how care is provided. This study addressed many of the questions facing NP patient outcomes as it is currently being debated in the news. Many individuals look at years of practice and degrees, whether you are a true doctor or not. However, this study reflects at what is important, which is that NP’s deliver quality care and improve patient outcomes that are very similar to MD care and Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 10 outcomes. This study increases to the current literature on NP care and outcomes and shows how research continues to expand and disseminate for our colleagues to become aware. The Well Women Program: An NP Intervention References American Academy of Nurse Practitioners. (2009). Nurse Practitioner Facts. Retrieved 3/11/2009, from http://www.aanp.org/NR/rdonlyres/54B71B02-D4DB-4A53-9FA6 23DDA0EDD6FC/0/NPFacts6.pdf Bishop, C. S. (2009). The critical role of the oncology nurse practitioners in cancer care: future implications. Leadership and Professional Development, 36(3), 267-269. Cooper, R. A. (2002). There’s a shortage of specialists. Is anyone listening? Academic Medicine, 77(8), 761-766. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic Review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819-823. Landro, L. (2008). The informed patient: Making room for ‘Dr. Nurse’. Wall Street Journal, D-1. Lenz, E. R., Mundinger, M.O., Hopkins, S.C., Lin, S.X. & Smolowitz, J.L. (2002). Diabetes care processes and outcomes in patientstreated by nurse practitioners or physicians. The Diabetes Educator, 28(4), 566-597. Lenz, E. R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. (2004). Primary care Running head: EFFECTIVENESS OF NURSE PRACTITIONERS 11 outcomes in patients treated by nurse practitioners or physicians: Two year follow-up. Medical Care Research and Review, 61(3), 332-351. Marion, L. C., Finnegan, L., Campbell, R.T., & Szalacha, L.A. (2009). The well women program: A community-based randomized trial to prevent sexually transmitted infection in low-income African American women. Research in Nursing & Health, 32, 274-285. Nursing League for Nursing. (1979). Position statement on the education of nurse practitioners. New York: Author. Sackett, D. L., Spitzer, W.O., Gent, M., & Roberts, R.S. (1974). The Burlington randomized trial of the nurse practitioner: Health outcomes of patients. The Nurse Practitioner, 9(2), 44- 45. Venning, P., Durie, A., Roland, M., Roberts, C., & Leese, B. (2000). Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal, 320(15), 1048-1053. Wheeler, K., & Haber, J. (2004). Development of psychiatric-mental health nurse practitioner competencies: Opportunities for the 21st century. Journal of the American Psychiatric Nurses Association, 10(3), 129-138. Young, T. (2005). Utilizing oncology nurse practitioners: A model Strategy. Community Onocolgy, 2(3), 218-224.
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