Comparison Studies - NP, Physician, and PA

[blindedmewithscience]

I though about the best place to put this thread and considering this section is dedicated to NPs and other clinicians, I'll place it here. Bellow I have listed comparisons between physician and NPs. I have also provided a comparison study between NPs and PAs. I'm looking to read comments about what people think of these studies. The reason I am posting these studies (all found on Pubmed), with links, is so people in this forum can use scientific studies on the subject rather than opinions. I have bolded all the statements that make the comparisons.

jama.jamanetwork.com/article.aspx?articleid=192259 - "No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05)."

ncbi.nlm.nih.gov/pmc/articles/PMC4493821/pdf/12960_2015_Article_49.pdf - "While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported."

ncbi.nlm.nih.gov/pmc/articles/PMC4466759/pdf/bmjopen-2014-007167.pdf - "11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly."

ncbi.nlm.nih.gov/pubmed/26836900 - "Among 9,066 admissions, there was no difference in 90-day survival for patients cared for by ACNP or resident teams (adjusted hazard ratio

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, 0.94; 95% CI, 0.85-1.04; P = .21). Although patients cared for by ACNPs had lower ICU mortality (6.3%) than resident team patients (11.6%; adjusted OR, 0.77; 95% CI, 0.63-0.94; P = .01), hospital mortality was not different (10.0% vs 15.9%; adjusted OR, 0.87; 95% CI, 0.73-1.03; P = .11). ICU length of stay was similar between the ACNP and resident teams (3.4 ± 3.5 days vs 3.7 ± 3.9 days [adjusted OR, 1.01; 95% CI, 0.93-1.1; P = .81]), but hospital length of stay was shorter for patients cared for by ACNPs (7.9 ± 11.2 days) than for resident patients (9.1 ± 11.2 days) (adjusted OR, 0.87; 95% CI, 0.80-0.95; P = .001)."

ncbi.nlm.nih.gov/pubmed/25643375 - Results aspect of abstract - "Participants in the MD-only cohort had significantly less orientation and independence in activities of daily living compared to participants in the NP/PA-dominant cohort. Other study variables did not vary significantly by practice model. Although the study provides some evidence that NP/PA involvement is associated with improved functioning, it is premature to draw strong inferences."

ncbi.nlm.nih.gov/pubmed/25443307 - "Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p<0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5-24.5, p<0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n=766, pooled relative risk (RR): 0.69, 95%CI: 0.34-1.43, I(2)=0%) and any re-hospitalisation up to 180 days (n=800, pooled RR: 0.87, 95%CI: 0.69-1.09, I(2)=32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32-0.94, p=0.03) and 180 days (RR: 0.62, 95%CI: 0.40-0.95, p=0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p<0.05)."

ncbi.nlm.nih. gov/pubmed/25167081 - "Twenty-one ICUs (72.4%) reported NP/PA participation in direct patient care. Patients in ICUs with NPs/PAs had lower mean Acute Physiology Scores (42.4 vs 46.7, P < .001) and mechanical ventilation rates (38.8% vs 44.2%, P < .001) than ICUs without NPs/PAs. Unadjusted and risk-adjusted mortality was similar between groups (adjusted relative risk, 1.10; 95% CI, 0.92-1.31). This result was consistent in all examined subgroups." Note: Those scores correlate with patient illness severity. For example, lower scores correlate with higher likelihood of survivability.

ncbi.nlm.nih. gov/pmc/articles/PMC4065389/pdf/1472-6963-14-214.pdf - “24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies.”

ncbi.nlm.nih.gov/pubmed/23450599 – “We found no significant difference between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and health-care costs.

ncbi.nlm.nih.gov/pubmed/21311842 – “The degree of disease control in stable childhood asthma managed by an asthma nurse is not inferior to traditional management by primary or secondary care physicians. The results also suggest that a lower review frequency does not detract from good disease control.”

Two points for clarification (restating some of the main points):

1 - There are no opinions by the author of this post expressed in this post.

2 - Why should you stay on topic? Because whether you are trying to prove that NPs or PAs lack the knowledge to be independent providers or that NPs or PAs should practice independently because of their backgrounds and other healthcare issues, you should be trying to support your points with scientific evidence. If you find the current studies are lacking in depth or quality, you should be striving to create standards, so that a study can be performed hopefully proving your point. Your thoughts on what those standards should be, should be a part of your reply to this thread (the more specific you can get, the better). This is not a place to state anecdotal evidence, make assumptions, or reply with irrelevant information, and I ask that those people please use the search bar to find the large number of threads that have those responses (if that is your goal).

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[GimpGenius]

 

[deleted480308]

please point out which studies were using non-physician supervised midlevels...

 

[Makati2008]

please point out which studies were using non-physician supervised midlevels...

Another issue is that on average the NPs in these cases get the patients that aren't as critically ill as those the residents/Attendings pick up. I do know that on my icu rotation it was disturbing to see how they practiced. It did make me realize that it's pretty hard to kill folks in general.


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[blindedmewithscience]

Another issue is that on average the NPs in these cases get the patients that aren't as critically ill as those the residents/Attendings pick up. I do know that on my icu rotation it was disturbing to see how they practiced. It did make me realize that it's pretty hard to kill folks in general.


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please point out which studies were using non-physician supervised midlevels...

Here's information from the first study:

"The opportunity to compare the 2 types of providers was made possible by several practice and policy innovations at the Columbia Presbyterian Center of New York Presbyterian Hospital in New York City. In 1993 when the medical center sought to establish new primary care satellite clinics in the community, the nurse practitioner faculty were asked to staff 1 site independently for adult primary care. This exclusively nurse practitioner practice was to be similar to the clinics staffed by physicians. All are located in the same neighborhood, serve primarily families from the Dominican Republic who are eligible for Medicaid, and follow the policies and procedures of the medical center. The nurse practitioner practice, the Center for Advanced Practice, opened in the fall of 1994.

New York State law allows nurse practitioners to practice with a collaboration agreement that requires the physician to respond when the nurse practitioner seeks consultation. Collaboration does not require the collaborating physician to be on site and requires only quarterly meetings to review cases selected by the nurse practitioner and the physician. The state also grants nurse practitioners full authority to prescribe medications, as well as reimbursement by Medicaid at the same rate as physicians. The medical board granted nurse practitioners who were faculty members in the school of nursing hospital admitting privileges, thereby making the basic outpatient services, payment, and provider responsibilities the same in the nurse practitioner and physician primary care practices. Additionally, nurse practitioners and physicians in the study were subject to the same hospital policy on productivity and coverage, and a similar number of patients were scheduled per session in each clinic.

While it has been posited that nurse practitioners have a differentiated practice pattern focused on prevention with lengthier visits,7 this study was purposely designed to compare nurse practitioners and physicians as primary care providers within a conventional medical care framework in the same medical center, where all other elements of care were identical. Nurse practitioners provided all ambulatory primary care, including 24-hour call, and made independent decisions for referrals to specialists and hospitalizations. The Spanish language ability of the nurse practitioners and physicians was similar, although the physicians had somewhat better Spanish facility on average. All of the nurse practitioners (n = 7) and most of the physicians (n = 11) had limited knowledge of Spanish, and 6 physicians were either fluent or bilingual. Staff who served as interpreters were available at each study site. The central hypothesis was that the selected outcomes would not differ between the patients of nurse practitioners and physicians."

I'll try to dig up information on the other studies. The problem is that some studies might have combined supervised and unsupervised data, along with illness severity. It might also be noted that even when there was physician supervision, that might not be on-site or even daily. Because in clinical environments, it's very difficult to impose experimental procedures. Therefore, not everything will be standardized. That does not mean we should be dismissive of these studies. In fact, that first study tried to standardize as many factors as possible.

 

[blindedmewithscience]

Double post.

 

[deleted480308]

Here's information from the first study:

"The opportunity to compare the 2 types of providers was made possible by several practice and policy innovations at the Columbia Presbyterian Center of New York Presbyterian Hospital in New York City. In 1993 when the medical center sought to establish new primary care satellite clinics in the community, the nurse practitioner faculty were asked to staff 1 site independently for adult primary care. This exclusively nurse practitioner practice was to be similar to the clinics staffed by physicians. All are located in the same neighborhood, serve primarily families from the Dominican Republic who are eligible for Medicaid, and follow the policies and procedures of the medical center. The nurse practitioner practice, the Center for Advanced Practice, opened in the fall of 1994.

New York State law allows nurse practitioners to practice with a collaboration agreement that requires the physician to respond when the nurse practitioner seeks consultation. Collaboration does not require the collaborating physician to be on site and requires only quarterly meetings to review cases selected by the nurse practitioner and the physician. The state also grants nurse practitioners full authority to prescribe medications, as well as reimbursement by Medicaid at the same rate as physicians. The medical board granted nurse practitioners who were faculty members in the school of nursing hospital admitting privileges, thereby making the basic outpatient services, payment, and provider responsibilities the same in the nurse practitioner and physician primary care practices. Additionally, nurse practitioners and physicians in the study were subject to the same hospital policy on productivity and coverage, and a similar number of patients were scheduled per session in each clinic.

While it has been posited that nurse practitioners have a differentiated practice pattern focused on prevention with lengthier visits,7 this study was purposely designed to compare nurse practitioners and physicians as primary care providers within a conventional medical care framework in the same medical center, where all other elements of care were identical. Nurse practitioners provided all ambulatory primary care, including 24-hour call, and made independent decisions for referrals to specialists and hospitalizations. The Spanish language ability of the nurse practitioners and physicians was similar, although the physicians had somewhat better Spanish facility on average. All of the nurse practitioners (n = 7) and most of the physicians (n = 11) had limited knowledge of Spanish, and 6 physicians were either fluent or bilingual. Staff who served as interpreters were available at each study site. The central hypothesis was that the selected outcomes would not differ between the patients of nurse practitioners and physicians."

I'll try to dig up information on the other studies. The problem is that some studies might have combined supervised and unsupervised data, along with illness severity. It might also be noted that even when there was physician supervision, that might not be on-site or even daily. Because in clinical environments, it's very difficult to impose experimental procedures. Therefore, not everything will be standardized. That does not mean we should be dismissive of these studies. In fact, that first study tried to standardize as many factors as possible.

The problem is that supervised nurses can't be compared as the "option" to physicians so unless you discard all those studies this while tread doesn't work. And calling it a collaboration doesn't pass either, if I have a more highly trained professional legally bound to give me instructions when I admit I'm over my head then I'm not independent.

 

[BlackDynamite]

Do you really want someone caring for your family that can't interpret the results of their own "study."


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[GimpGenius]

There's also mention of "procedures and protocols" without any further explanation. Is it protocol for an NP to call the collaborating physician for referral if BP, a1c, etc. hits a certain number? Without knowing what the systems limitations are on clinicians, it's difficult to argue a true parity in patient outcomes.

Really, the NP researchers need to get some long term studies going head to head with physicians in areas where they have complete autonomy. Look at m&m, referals, average cost per patient, etc. Until that happens, this whole thread is a NP vs. MD/DO peeing contest.

And we all know who wins those: urologists.

 

[762513]

Here's information from the first study:

"The opportunity to compare the 2 types of providers was made possible by several practice and policy innovations at the Columbia Presbyterian Center of New York Presbyterian Hospital in New York City. In 1993 when the medical center sought to establish new primary care satellite clinics in the community, the nurse practitioner faculty were asked to staff 1 site independently for adult primary care. This exclusively nurse practitioner practice was to be similar to the clinics staffed by physicians. All are located in the same neighborhood, serve primarily families from the Dominican Republic who are eligible for Medicaid, and follow the policies and procedures of the medical center. The nurse practitioner practice, the Center for Advanced Practice, opened in the fall of 1994.

New York State law allows nurse practitioners to practice with a collaboration agreement that requires the physician to respond when the nurse practitioner seeks consultation. Collaboration does not require the collaborating physician to be on site and requires only quarterly meetings to review cases selected by the nurse practitioner and the physician. The state also grants nurse practitioners full authority to prescribe medications, as well as reimbursement by Medicaid at the same rate as physicians. The medical board granted nurse practitioners who were faculty members in the school of nursing hospital admitting privileges, thereby making the basic outpatient services, payment, and provider responsibilities the same in the nurse practitioner and physician primary care practices. Additionally, nurse practitioners and physicians in the study were subject to the same hospital policy on productivity and coverage, and a similar number of patients were scheduled per session in each clinic.

While it has been posited that nurse practitioners have a differentiated practice pattern focused on prevention with lengthier visits,7 this study was purposely designed to compare nurse practitioners and physicians as primary care providers within a conventional medical care framework in the same medical center, where all other elements of care were identical. Nurse practitioners provided all ambulatory primary care, including 24-hour call, and made independent decisions for referrals to specialists and hospitalizations. The Spanish language ability of the nurse practitioners and physicians was similar, although the physicians had somewhat better Spanish facility on average. All of the nurse practitioners (n = 7) and most of the physicians (n = 11) had limited knowledge of Spanish, and 6 physicians were either fluent or bilingual. Staff who served as interpreters were available at each study site. The central hypothesis was that the selected outcomes would not differ between the patients of nurse practitioners and physicians."

I'll try to dig up information on the other studies. The problem is that some studies might have combined supervised and unsupervised data, along with illness severity. It might also be noted that even when there was physician supervision, that might not be on-site or even daily. Because in clinical environments, it's very difficult to impose experimental procedures. Therefore, not everything will be standardized. That does not mean we should be dismissive of these studies. In fact, that first study tried to standardize as many factors as possible.

Excellent post. You defended the profession much better than I did. This is a study directly answering the question asked. If posters were interested in actual intellectual debate they would post their own, stronger evidence to refute what your study has shown. No one is interested in providing evidence, they simply wish to attack what you provide. Thanks for the well researched and thoughtful post.

 

[GimpGenius]

.

 

[blindedmewithscience]

The problem is that supervised nurses can't be compared as the "option" to physicians so unless you discard all those studies this while tread doesn't work. And calling it a collaboration doesn't pass either, if I have a more highly trained professional legally bound to give me instructions when I admit I'm over my head then I'm not independent.

I believe in the first study, the NPs were practicing independently on a daily basis. Since I posted the results/conclusions of nine different studies for physician and NP comparisons, you might find many states, where the NPs did practice independently. I did not go thoroughly through all the research methods to determine where each study was conducted in. I posted the independent practices of the NPs of the first study, published in JAMA, which should allow for those comparisons. The other studies might have NPs with similar practices and I'll try sometime in the future to go through that information (the information I reviewed pertained to data validity). I welcome people to comment on that first study that addresses those concerns, with free public access, and review the other studies, with the links provided.

Do you really want someone caring for your family that can't interpret the results of their own "study."


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I have not reviewed all the authors from every study I gathered from Pubmed. The majority I did review had NP and MD co-authors involved throughout the process, meaning both were involved in conducting and interpreting the studies. NPs have backgrounds in statistics, so I think both NPs and physicians should be able to interpret research studies.

There's also mention of "procedures and protocols" without any further explanation. Is it protocol for an NP to call the collaborating physician for referral if BP, a1c, etc. hits a certain number? Without knowing what the systems limitations are on clinicians, it's difficult to argue a true parity in patient outcomes.

Really, the NP researchers need to get some long term studies going head to head with physicians in areas where they have complete autonomy. Look at m&m, referals, average cost per patient, etc. Until that happens, this whole thread is a NP vs. MD/DO peeing contest.

And we all know who wins those: urologists.

While it has been posited that nurse practitioners have a differentiated practice pattern focused on prevention with lengthier visits,7 this study was purposely designed to compare nurse practitioners and physicians as primary care providers within a conventional medical care framework in the same medical center, where all other elements of care were identical. Nurse practitioners provided all ambulatory primary care, including 24-hour call, and made independent decisions for referrals to specialists and hospitalizations.

Again, the practices were very similar between the two studies and if they suspected a patient needed to see a specialist, they would have done that independently. Meaning if glycated hemoglobin was above some threshold, they might refer to an endocrinologist. But, independent practice at least for the first study, might not have been an issue.

As for the other points regarding a long-term study, this was done initially and over a 6 month period, where the patient outcomes were relatively the same. Because these were observational studies, you would need patients in the same stages of a disease to compare m&m. Meaning if physicians had patients with later stages of diabetes, there might be a major difference with m&m values. As far as cost per treatment, whether that be through referrals, tests, time spent per patient, etc., it should be noted that independent quality of care needs to be investigated, before exploring which is the cheaper option. And there are so many ways to interpret that cost data, many of which might not be relevant to a clinical setting.

This means in my opinion that there needs to be data on whether NPs can diagnose and treat, with the same accuracy or better, than physicians. Although you could create a long-term study to investigate each disorder, that might take decades, during a time where NP and physician education will be changing (making the studies irrelevant). And to gather those patients to be reviewed by NPs and physicians, would be cost prohibitive (for example, flying patients in from out-of-state). The most conclusive study I believe you will get for observational clinical comparisons, is looking in an area, like this study, with similar patient populations, and comparing the disorder data that's available (and that is what they attempted to do in this study to a large degree). Other studies I listed tried to do that either in the same setting or with other patient populations (i.e. ICU).

Excellent post. You defended the profession much better than I did. This is a study directly answering the question asked. If posters were interested in actual intellectual debate they would post their own, stronger evidence to refute what your study has shown. No one is interested in providing evidence, they simply wish to attack what you provide. Thanks for the well researched and thoughtful post.

If people like this, I'd appreciate if they can spread the word about these studies in their respective forums (Allnurses) to gather more opinions about the subject.

 

[deleted480308]

I believe in the first study, the NPs were practicing independently on a daily basis. Since I posted the results/conclusions of nine different studies for physician and NP comparisons, you might find many states, where the NPs did practice independently. I did not go thoroughly through all the research methods to determine where each study was conducted in. I posted the independent practices of the NPs of the first study, published in JAMA, which should allow for those comparisons. The other studies might have NPs with similar practices and I'll try sometime in the future to go through that information (the information I reviewed pertained to data validity). I welcome people to comment on that first study that addresses those concerns, with free public access, and review the other studies, with the links provided.

Focusing on the first study there a number of problems that really fly out at me...

1) It relies on self-reported metrics of health which are ridiculously prone to bias and mis-reporting. The sf36 form should not in any way be considered a basis for determining a professional's skill.
2) The utilitization category mentions only # of visits by type and over such a short period of time that it's unlikely to come up with a difference. They didn't track # of tests ordered or number/cost of meds prescribed
3) measuring peak flow for management of asthma without noting if those patients are in some level of episode is not as useful as it's being implied

it's a decent setting to try and run a trial......but it's got a lot of problems to be solved before anyone can say it means nurses are comparable

 

[762513]

Focusing on the first study there a number of problems that really fly out at me...

1) It relies on self-reported metrics of health which are ridiculously prone to bias and mis-reporting. The sf36 form should not in any way be considered a basis for determining a professional's skill.
2) The utilitization category mentions only # of visits by type and over such a short period of time that it's unlikely to come up with a difference. They didn't track # of tests ordered or number/cost of meds prescribed
3) measuring peak flow for management of asthma without noting if those patients are in some level of episode is not as useful as it's being implied

it's a decent setting to try and run a trial......but it's got a lot of problems to be solved before anyone can say it means nurses are comparable

True, SB247, there are some improvements to future methodology to be made in this study, as well as most published studies in all fields of medicine.

1- The cost issue is a non-issue; the price of an week long ICU admission following a CVA from a uncontrolled hypertensive who could not find a primary care provider in time pales in comparison to a NP ordering an occasional CT that may not be needed.

2- Please post your stronger evidenced comparison study from the many states allowing independent NP practice showing unsafe NP care. That way we can compare the strength of that study versus this one and have a more honest debate.

 

[deleted480308]

True, SB247, there are some improvements to future methodology to be made in this study, as well as most published studies in all fields of medicine.

1- The cost issue is a non-issue; the price of an week long ICU admission following a CVA from a uncontrolled hypertensive who could not find a primary care provider in time pales in comparison to a NP ordering an occasional CT that may not be needed.

2- Please post your stronger evidenced comparison study from the many states allowing independent NP practice showing unsafe NP care. That way we can compare the strength of that study versus this one and have a more honest debate.

#1....it's not a "non-issue" if the study is claiming equal health resource utilizationi

#2....that's not how studies work in health. You don't run a study to prove something is a bad idea. It would be unethical, as the one positing that nurses aren't comparable to start a study where I sent patients to independent nurses. The onus is on the side making the claim of their equivalence to provide a solid and believable study. If you are tired of people pointing out the large and clear holes in these studies, then get better studies.

 

[762513]

#1....it's not a "non-issue" if the study is claiming equal health resource utilizationi

#2....that's not how studies work in health. You don't run a study to prove something is a bad idea. It would be unethical, as the one positing that nurses aren't comparable to start a study where I sent patients to independent nurses. The onus is on the side making the claim of their equivalence to provide a solid and believable study. If you are tired of people pointing out the large and clear holes in these studies, then get better studies.

1. The study clearly states healthcare outcomes, not health resource utilization. You often change the premise of the argument to fit whatever viewpoint you shift to.

2. We study research questions in healthcare. The research question being studied is do NP's have safe patient care comparable to MD's. A study was provided that shows this is the case. Your observations showing that methodology could be strengthened in further studies does nothing to invalidate the study itself.

 

[deleted480308]

1. The study clearly states healthcare outcomes, not health resource utilization. You often change the premise of the argument to fit whatever viewpoint you shift to.

2. We study research questions in healthcare. The research question being studied is do NP's have safe patient care comparable to MD's. A study was provided that shows this is the case. Your observations showing that methodology could be strengthened in further studies does nothing to invalidate the study itself.

#1..... It did claim to show equal utilization but the metrics used were significantly inadequate for such a claim....From the study text.....

Utilization
For our comparison of outcomes we analyzed utilization of health care services for nurse practitioner and physician patients who enrolled in the study by keeping their initial primary care appointment. There were no statistically significant differences between the nurse practitioner and physician patients for any category of service during either the first 6 months or the first year after the initial primary care visit for either unadjusted or adjusted use rates (Table 4). When the utilization analyses were repeated for the subsets of "sickest" patients as defined in the "Self-reported Health Status" section above, no differences were found in the health care services utilization between the nurse practitioner and physician patients (Table 5). In the 6 months and 1 year after the initial primary care visit, enrolled patients in both groups made significantly more primary care and specialty visits and fewer emergency/urgent visits than in the 6 months prior to recruitment. The percentage of enrolled patients hospitalized was not significantly different for either 6 months or 1 year after the initial primary care appointment.

#2..... At a certain point, "could be strengthened" becomes "doesn't provide the evidence it claims to provide" (see wakefield). We would never approve a new drug based on this level of evidence and we should pretend it's adequate justification for allowing autonomy to a another profession besides physicians

 

[BlackDynamite]

"We have less training and can practice medicine better than physicians!"

"We've done enough training. We're finished learning, and we're ready to practice!"

You're not going anywhere near my family.

I mean seriously? People starting careers... Have some respect for yourself and don't be that person. Own up to your deficiencies and be good at what you are... A nurse... Trained for nursing. Don't go kill patients just because the majority of voters are idiots and will let you. Have some responsibility. Jeez.


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[Boatswain2PA]

All these variously flawed studies also take place in systems that were heavily influenced by physicians.

Remove the physicians from the general oversight and you will have greater problems.

Bottom line - wanna practice medicine independently, then go to MD/DO school.

 

[762513]

"We have less training and can practice medicine better than physicians!"

"We've done enough training. We're finished learning, and we're ready to practice!"

You're not going anywhere near my family.

I mean seriously? People starting careers... Have some respect for yourself and don't be that person. Own up to your deficiencies and be good at what you are... A nurse... Trained for nursing. Don't go kill patients just because the majority of voters are idiots and will let you. Have some responsibility. Jeez.


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lol troll. Show me where anyone has actually said that as is implied from your use of quotations.

 

[BlackDynamite]

lol troll. Show me where anyone has actually said that as is implied from your use of quotations.

No.


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[VA Hopeful Dr]

I though about the best place to put this thread and considering this section is dedicated to NPs and other clinicians, I'll place it here. Bellow I have listed comparisons between physician and NPs. I have also provided a comparison study between NPs and PAs. I'm looking to read comments about what people think of these studies. The reason I am posting these studies (all found on Pubmed), with links, is so people in this forum can use scientific studies on the subject rather than opinions. I have bolded all the statements that make the comparisons.

jama.jamanetwork.com/article.aspx?articleid=192259 - "No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05)."

A) 6 months doesn't impress anyone, especially not for diseases that takes years (if not decades) to cause problems. B) No mention was made of appointment length. Traditionally, NPs have more time/patient which can make a huge difference. C) Agree with SB, I want to know more about resource utilization.

ncbi.nlm.nih.gov/pmc/articles/PMC4493821/pdf/12960_2015_Article_49.pdf - "While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported."

HAHAHAHA. Seriously, a journal I've never heard of and a conclusion that lists out all that issues with the review including "small number of studies, low reporting standards, clinician characteristics, and quality of studies".

ncbi.nlm.nih.gov/pmc/articles/PMC4466759/pdf/bmjopen-2014-007167.pdf - "11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly."

Once again the article lists out the weaknesses of the review in question. Beyond that, the BMJ Open (journal in question) has a 55% article acceptance rate. For comparison, the NEJM has a 5% rate, JAMA has a 9% rate. Now, let's brief look at the 10 trials they reviewed in order by Table 1 in the article..

1. Dutch study, 2 week f/u, GPs signed off on all prescriptions. Worthless.
2. UK study, 4 week f/u, GPs signed off on all scripts. Worthless
3. Potentially good study
4. UK study, 2 week f/u, GPs signed off on all scripts. Worthless.
5. Scope money trial. I can train anyone to do colonoscopies, that's the easy part of being a GI doctor. Worthless.
6. Dutch study, eczema treatment only - again, treating eczema is easy. My golden retriever can treat eczema. Worthless.
7. Potentially good study
8. NP care based on algorithms, required permission to change meds. Mostly looks like a lifestyle modification trial. Mostly worthless, though I wouldn't mind having an NP run diabetes lifestyle treatment clinic available so have at it.
9. NP care augmented (not replaced) physician care in the study group, even the review noted a high risk of bias. Worthless.
10. 4 NPs with 101 patients, 15 physicians with 105 patients. You're running a high risk of a single less than optimal physician in that group screwing up the results.
12. NP versus "usual ED physician directed follow-up" which usually means no f/u. Nice try.

Now among those potentially good studies (3, 7, and 10) all of those produced results described by the review authors as "weak".

ncbi.nlm.nih.gov/pubmed/26836900 - "Among 9,066 admissions, there was no difference in 90-day survival for patients cared for by ACNP or resident teams (adjusted hazard ratio

---

, 0.94; 95% CI, 0.85-1.04; P = .21). Although patients cared for by ACNPs had lower ICU mortality (6.3%) than resident team patients (11.6%; adjusted OR, 0.77; 95% CI, 0.63-0.94; P = .01), hospital mortality was not different (10.0% vs 15.9%; adjusted OR, 0.87; 95% CI, 0.73-1.03; P = .11). ICU length of stay was similar between the ACNP and resident teams (3.4 ± 3.5 days vs 3.7 ± 3.9 days [adjusted OR, 1.01; 95% CI, 0.93-1.1; P = .81]), but hospital length of stay was shorter for patients cared for by ACNPs (7.9 ± 11.2 days) than for resident patients (9.1 ± 11.2 days) (adjusted OR, 0.87; 95% CI, 0.80-0.95; P = .001)."

---

This has been discussed elsewhere, but resident care is not the gold standard - attending is. Plus, the NPs were not independent in this study. Plus, ICU mortality for NPs was better but overall hospital mortality was not - this means more of the NPs patients died outside the ICU. We can argue what that means, but likely nothing good. Length of stay is also longer for residents than for anyone else, this isn't news - its called learning.

ncbi.nlm.nih.gov/pubmed/25643375 - Results aspect of abstract - "Participants in the MD-only cohort had significantly less orientation and independence in activities of daily living compared to participants in the NP/PA-dominant cohort. Other study variables did not vary significantly by practice model. Although the study provides some evidence that NP/PA involvement is associated with improved functioning, it is premature to draw strong inferences."

Can't read the full article so can't comment other than - nursing journal, no physician authors.

ncbi.nlm.nih.gov/pubmed/25443307 - "Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p<0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5-24.5, p<0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n=766, pooled relative risk (RR): 0.69, 95%CI: 0.34-1.43, I(2)=0%) and any re-hospitalisation up to 180 days (n=800, pooled RR: 0.87, 95%CI: 0.69-1.09, I(2)=32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32-0.94, p=0.03) and 180 days (RR: 0.62, 95%CI: 0.40-0.95, p=0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p<0.05)."

Let me just leave the conclusion from the abstract here:

CONCLUSIONS:
Given the low quality evidence, weak economic analyses, small sample sizes, and small number of nurse practitioners evaluated in each study, evidence of the cost-effectiveness of nurse practitioner-transitional care is inconclusive and further research is needed.

ncbi.nlm.nih. gov/pubmed/25167081 - "Twenty-one ICUs (72.4%) reported NP/PA participation in direct patient care. Patients in ICUs with NPs/PAs had lower mean Acute Physiology Scores (42.4 vs 46.7, P < .001) and mechanical ventilation rates (38.8% vs 44.2%, P < .001) than ICUs without NPs/PAs. Unadjusted and risk-adjusted mortality was similar between groups (adjusted relative risk, 1.10; 95% CI, 0.92-1.31). This result was consistent in all examined subgroups." Note: Those scores correlate with patient illness severity. For example, lower scores correlate with higher likelihood of survivability.

Once again, the conclusion:

CONCLUSIONS:
NPs/PAs appear to be a safe adjunct to the ICU team.

Note: ADJUNCT. We all know that a second set of eyes is always a good thing - especially in ICUs. Its why ICU nurses are usually the best/brightest and have the most leeway as to what they can do.

There is also no note of patient load for midlevels versus patient load for MDs.

ncbi.nlm.nih. gov/pmc/articles/PMC4065389/pdf/1472-6963-14-214.pdf - “24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies.”

I like this one. Let me pick out a few neat points from the Results...

For single-issue urgent care type visits (in small or poor quality RCTs), nurse-led care reduced mortality and admissions. Not compared to physicians, just in general. This should surprise no one - NPs are usually better than nothing. In higher quality RCTs, nurse-led teams actually had higher mortality and admission rates. Oops.

ncbi.nlm.nih.gov/pubmed/23450599 – “We found no significant difference between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and health-care costs.

This was a neat review. Several problems though...

In two studies, the asthma nurse worked strictly according to an algorithm derived from guidelines, whereas the physician in the control group had to work according to same guideline - well duh, if you give 2 people the same exact rules to follow you're going to end up with similar results.

In the two studies there were co-interventions at the beginning of a follow-up period, without an apparently similar co-intervention in the control group - So the NP group got extra asthma training before the trial began, interesting...

Now, let's look at outcomes. Of the 5 trials, only 1 was done with patients whose asthma wasn't stable (if they're stable, a trained RN could manage asthma). That group had only 157 patients. Despite that, the NP group had 25% more exacerbations but this wasn't significant due to small sample size.

All of the other outcomes only had 1 trial to look at and those were all on stable patients so I really don't care about those.

ncbi.nlm.nih.gov/pubmed/21311842 – “The degree of disease control in stable childhood asthma managed by an asthma nurse is not inferior to traditional management by primary or secondary care physicians. The results also suggest that a lower review frequency does not detract from good disease control.”

The degree of disease was unchanged, but the GP's had significantly fewer regular visits with no difference in acute visits - so basically we did the same job for much cheaper. Isn't that weird...


Man, that was grueling. Long story short: none of this is all that impressive and some of it even goes against the narrative you'd like to paint.

 

[deleted480308]

^

 

[blindedmewithscience]

So, I decided not to respond to each reply line by line (I may do that at a later time), but the point of this thread was to get feedback on the articles that could be used to improve these types of studies. This would mean that sometime in the future a direct comparison could be made between the different professionals (physician, NP, and PA), within different specialties. While many responses pertain to the articles listed, some are not relevant to what's being asked in this thread. This includes, but not limited to, your opinion(s) on the subject, anecdotal evidence, types of authors in the study (since that fact does not mean anything about methods or analysis errors), peer-reviewed journal acceptance rate (since this is not relevant to study methods or results/conclusions), and situations that don't fit a particular specialty. Now for the relevant replies, I will start off with issues about adequacy. If one result was not sufficient, it would be good to know what the article should have done to make for a better comparison, with exception to issues that are self-explanatory, such as sample size or data reporting. If utilization was an issue, for example, what would you like to have seen to where physicans and NPs could be compared?

The bigger question would be what would be an adequate way of having a comparison? It might not be possible to have a study with drug trial formatting (double-blind...), because of cost and the amount of disorders a human can have. In addition, it should be noted that you can find fault in any study. By the same token, there should be studies done that are more standardized on the subject to reflect efficacy within a specialty. And I am trying to get people to respond to what those standards should be, to reduce bias. I'd also like to address one final point.

Man, that was grueling. Long story short: none of this is all that impressive and some of it even goes against the narrative you'd like to paint.

This is not true. If you noticed in my first post, I did not give any opinions about any of the articles, all article information was in quotes, and I put in bold ANY comparisons between the specialties (physicians or PAs outperformed NPs, no significant difference in performance, NPs outperformed physicians or PAs). I posted articles that made comparisons between the providers found on Pubmed and those direct comparisons are presented in quotes. I'd also like to not to have statements like this posted, to avoid invoking "flame wars". Also, please read above about relevance.

 

[deleted480308]

It's disengenuous to pretend you don't have an ideological bent here...we have preconceived notions and that's ok, just 'fess up to them

As to the study that would mean something?..., huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits, cost and number of tests/imaging ordered, number of referals to specialists, number of patients per nurse/doctor, number of support staff per nurse/doctor, cost/# of meds prescribed and then all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical.

Trouble is that is hard to do. I personally think it's unethical to dump patients on unsupervised nurses and shouldn't be done at all but that's what it would take to convince me.

 

[hamstergang]

some are not relevant to what's being asked in this thread. This includes, but not limited to, ... types of authors in the study (since that fact does not mean anything about methods or analysis errors), peer-reviewed journal acceptance rate (since this is not relevant to study methods or results/conclusions)

Those are actually very relevant. I believe someone asked before about your level of training and I don't remember you responding, but it would be useful to know your background in evaluating studies in order to tailor an appropriate explanation.

This is not true. If you noticed in my first post, I did not give any opinions about any of the articles

Your posts definitely seem to have an opinion on the subject. If you feel others are mischaracterizing your opinion, then why not just explicitly state what you believe to avoid confusion?

 

[762513]

It's disengenuous to pretend you don't have an ideological bent here...we have preconceived notions and that's ok, just 'fess up to them

As to the study that would mean something?..., huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits, cost and number of tests/imaging ordered, number of referals to specialists, number of patients per nurse/doctor, number of support staff per nurse/doctor, cost/# of meds prescribed and then all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical.

Trouble is that is hard to do. I personally think it's unethical to dump patients on unsupervised nurses and shouldn't be done at all but that's what it would take to convince me.

Regardless of anyone's opinion that is what has been happening for decades. If these same studies had justified your opinion instead of the opposite opinion, would you be so quick to point out the ways in which the methodology would be improved? Certainly not, you are just as biased towards your position as the OP.

Furthermore the idea of a "collaborative agreement" is not very clear. This linked news article states some of the downfalls http://nurse-practitioners-and-phys...web.com/Article/Paying-for-Collaboration.aspx

The primary question is how often are these providers actually collaborating, as you have stated that a NP/PA does not provide the care of the patient if there is any collaboration with a physician involved, an opinion which I think you will adjust when you enter your practice. The ethical question is how likely is it that a physician who is employed by a nurse will bring up serious care issues?

NP's are already providing access to millions of patients who would not be able to see a provider, and the studies show and I think we can all agree that seeing any provider is better than going without care.

As far as healthcare cost utilization, while that is a problem to be addressed, access is the far scarier elephant in the room. Unless you can grow a couple hundred thousand physicians tomorrow trained and ready to enter primary care, the NP lobby has won.

 

[deleted480308]

Regardless of anyone's opinion that is what has been happening for decades. If these same studies had justified your opinion instead of the opposite opinion, would you be so quick to point out the ways in which the methodology would be improved? Certainly not, you are just as biased towards your position as the OP.

I'm pretty obnoxious about methodology and not making claims on something that isn't backed by it's supposed evidence. I absolutely would criticize a poorly designed study that called for something I wanted if it was a crappy study.

Furthermore the idea of a "collaborative agreement" is not very clear. This linked news article states some of the downfalls http://nurse-practitioners-and-phys...web.com/Article/Paying-for-Collaboration.aspx

The primary question is how often are these providers actually collaborating, as you have stated that a NP/PA does not provide the care of the patient if there is any collaboration with a physician involved, an opinion which I think you will adjust when you enter your practice. The ethical question is how likely is it that a physician who is employed by a nurse will bring up serious care issues?

NP's are already providing access to millions of patients who would not be able to see a provider, and the studies show and I think we can all agree that seeing any provider is better than going without care.

As far as healthcare cost utilization, while that is a problem to be addressed, access is the far scarier elephant in the room. Unless you can grow a couple hundred thousand physicians tomorrow trained and ready to enter primary care, the NP lobby has won.

The "too bad, we're doing it" argument doesn't remotely address the points I'm bringing up.... 1) unsupervised nurses are not as qualified as physicians and shouldn't be operating independently 2) these studies posted by OP do not offer compelling argument contrary to #1.

 

[762513]

The "too bad, we're doing it" argument doesn't remotely address the points I'm bringing up.... 1) unsupervised nurses are not as qualified as physicians and shouldn't be operating independently 2) these studies posted by OP do not offer compelling argument contrary to #1.[/QUOTE]

Lets suppose what you are saying is true. Why is it that no studies have found disparate outcomes?

 

[blindedmewithscience]

It's disengenuous to pretend you don't have an ideological bent here...we have preconceived notions and that's ok, just 'fess up to them

I did not state any opinions in that first post and asked people to provide comments on the studies. It should not be relevant for comments on these studies.

As to the study that would mean something?..., huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits, cost and number of tests/imaging ordered, number of referals to specialists, number of patients per nurse/doctor, number of support staff per nurse/doctor, cost/# of meds prescribed and then all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical.

This is the type of comment I was hoping to see. I'll try to respond to your points:

1 - huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits - Better sample sizes would be good. What duration are we talking about and how did you come up with that number? Although it would ideal to use completely independent NPs, there are populations of NPs, such as in rural medicine, that receive little to no oversight. For example, NPs that have not heard back for long periods of time from their supervising physicians and are practicing independently for those periods of time.

2 - cost and number of tests/imaging ordered - this seems to only be important if you are comparing the exact same patient. Although this might be important for future studies, it might be important to establish can those providers provide the same results, before exploring does it cost the same (since there are issues of availability).

3 - number of referrals to specialists - this would also only be valid if you were comparing the exact same patient, for example, late stage diabetes.

4 - number of patients per nurse/doctor - Are you referring to time spent per patient?

5 - number of support staff per nurse/doctor - I'd like to know hear more about this point.

6 - cost/# of meds prescribed - again, this is only relevant to the exact same cases. Also, patient responses (disorder progression) should be compared before cost of treatment

7 - all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical. - Although it would be important to only include objective data, maybe these surveys could be somehow incorporated into the study, since we are focusing on part of a medical business model.

Trouble is that is hard to do. I personally think it's unethical to dump patients on unsupervised nurses and shouldn't be done at all but that's what it would take to convince me.

This issue is important with NPs gaining independence to practice.

Those are actually very relevant. I believe someone asked before about your level of training and I don't remember you responding, but it would be useful to know your background in evaluating studies in order to tailor an appropriate explanation.

No, they are not. They are not relevant to research protocols or how data is interpreted. I also ask people to comment on the studies, not my background. This is a public forum and I'm not the only one interested in this type of feedback.

Your posts definitely seem to have an opinion on the subject. If you feel others are mischaracterizing your opinion, then why not just explicitly state what you believe to avoid confusion?

Because if I am not using opinion statements, I should not have to explicitly state that I am not using opinion statements, much like I would not state that the post is written in the English language, when all the words that I used are from that language. I will add that onto the original post for clarification, but that should not be necessary.

 

[deleted480308]

I did not state any opinions in that first post and asked people to provide comments on the studies. It should not be relevant for comments on these studies.



This is the type of comment I was hoping to see. I'll try to respond to your points:

1 - huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits - Better sample sizes would be good. What duration are we talking about and how did you come up with that number? Although it would ideal to use completely independent NPs, there are populations of NPs, such as in rural medicine, that receive little to no oversight. For example, NPs that have not heard back for long periods of time from their supervising physicians and are practicing independently for those periods of time.

2 - cost and number of tests/imaging ordered - this seems to only be important if you are comparing the exact same patient. Although this might be important for future studies, it might be important to establish can those providers provide the same results, before exploring does it cost the same (since there are issues of availability).

3 - number of referrals to specialists - this would also only be valid if you were comparing the exact same patient, for example, late stage diabetes.

4 - number of patients per nurse/doctor - Are you referring to time spent per patient?

5 - number of support staff per nurse/doctor - I'd like to know hear more about this point.

6 - cost/# of meds prescribed - again, this is only relevant to the exact same cases. Also, patient responses (disorder progression) should be compared before cost of treatment

7 - all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical. - Although it would be important to only include objective data, maybe these surveys could be somehow incorporated into the study, since we are focusing on part of a medical business model.



This issue is important with NPs gaining independence to practice.



Because if I am not using opinion statements, I should not have to explicitly state that I am not using opinion statements, much like I would not state that the post is written in the English language, when all the words that I used are from that language. I will add that onto the original post for clarification, but that should not be necessary.

cost is absolutely part of the equation, lying about being cheaper is part of how nurses have convinced legislatures to expand their scope

 

[blindedmewithscience]

cost is absolutely part of the equation, lying about being cheaper is part of how nurses have convinced legislatures to expand their scope

I did not say that. I said that patient health results should be first researched before having a study on cost, to avoid placing too many restrictions 0n a study (making it less feasible). We need to determine if NPs (or PAs depending on the study) can diagnose and produce the same patient outcomes, before studying cost, as independent practitioners. I also made a couple other points directed at your response, not related to cost.

 

[deleted480308]

I did not say that. I said that patient health results should be first researched before having a study on cost, to avoid placing too many restrictions 0n a study (making it less feasible). We need to determine if NPs (or PAs depending on the study) can diagnose and produce the same patient outcomes, before studying cost, as independent practitioners. I also made a couple other points directed at your response, not related to cost.

cost is ALWAYS part of the consideration

as for the time, if you're evaluating long term chronic diseases 6 months simply isn't long enough to evaluate skills for managing chronic issues

 

[762513]

cost is ALWAYS part of the consideration

as for the time, if you're evaluating long term chronic diseases 6 months simply isn't long enough to evaluate skills for managing chronic issues

Cost is important, but access is much, much more important. To do a true cost evaluation we would need to look at catastrophic illnesses that could have been prevented with access to primary care in rural communities who do not have access to an MD. These types of studies would be unethical and have extreme numbers of confounding factors and rival hypothesis. Cost analysis needs to be put on hold until safety has been determined up to the standard that you seem to require.

 

[blindedmewithscience]

cost is ALWAYS part of the consideration

as for the time, if you're evaluating long term chronic diseases 6 months simply isn't long enough to evaluate skills for managing chronic issues

I understand that cost is a factor in the decisions. However, it would be good to know if NPs (or again, PAs) can produce the same clinical results, before exploring what provider can do it in the most feasible manner. Think about it in terms of stages, if NPs cannot produce the same clinical results, as independent practitioners, why would you explore other factors like cost and clinical results in subsequent studies? This is important in areas for where there are not enough practitioners, where NPs want to practice independently. For timing, I get your point, but I want to establish what would be valid for that kind of study? 5 years? 10 years? 50 years? At some point, you are limiting the number of participants, depending on how many times people usually switch providers within a time period.

 

[deleted480308]

I understand that cost is a factor in the decisions. However, it would be good to know if NPs (or again, PAs) can produce the same clinical results, before exploring what provider can do it in the most feasible manner. Think about it in terms of stages, if NPs cannot produce the same clinical results, as independent practitioners, why would you explore other factors like cost and clinical results in subsequent studies? This is important in areas for where there are not enough practitioners, where NPs want to practice independently. For timing, I get your point, but I want to establish what would be valid for that kind of study? 5 years? 10 years? 50 years? At some point, you are limiting the number of participants, depending on how many times people usually switch providers within a time period.

It's a fallacy that NPs want to work in the underserved areas any more than the doctors do

 

[762513]

It's a fallacy that NPs want to work in the underserved areas any more than the doctors do

That's true, but can be impacted by education "A study of 30 graduates of the Northern Arizona University School of Nursing program that prepares NPs to work in rural areas found that 87 percent were working in rural practices." http://depts.washington.edu/uwrhrc/uploads/RHRC_PB147_Skillman.pdf

Even if the percentage of NP's and physicians working in rural practice is the same that still means hundreds of thousands of patients now have access to primary care they would not have if not for expanded NP practice laws.

 

[deleted480308]

That's true, but can be impacted by education "A study of 30 graduates of the Northern Arizona University School of Nursing program that prepares NPs to work in rural areas found that 87 percent were working in rural practices." http://depts.washington.edu/uwrhrc/uploads/RHRC_PB147_Skillman.pdf

Even if the percentage of NP's and physicians working in rural practice is the same that still means hundreds of thousands of patients now have access to primary care they would not have if not for expanded NP practice laws.

they are being given substandard care when compared to physicians, the solution to a perceived shortage in primary care is to train more doctors and pay primary more as an incentive to draw students. The solution to people needing more doctors is not to give them a bunch of people who aren't trained as well as doctors

 

[Instatewaiter]

Lets suppose what you are saying is true. Why is it that no studies have found disparate outcomes?

Because
1) they are published by NPs who have clear biases (Mundinger's group for instance)
2) in journals with not only poor peer review processes (just based alone on the poor quality of studies they will publish)
3) But also in journals with incentives to publish any garbage that will claim equivalence (Journal of Nursing Economic$)

With all the statistics fluff courses they make the DNPs take, you'd think they'd be able to produce a reasonable study.

 

[762513]

they are being given substandard care when compared to physicians, the solution to a perceived shortage in primary care is to train more doctors and pay primary more as an incentive to draw students. The solution to people needing more doctors is not to give them a bunch of people who aren't trained as well as doctors

Perceived shortage? Our country has to rely on foreign trained doctors just to continue not meeting our healthcare needs. Half of the residents at my hospital are foreign born and trained. Perceived shortage, don't make me laugh.

 

[deleted480308]

Perceived shortage? Our country has to rely on foreign trained doctors just to continue not meeting our healthcare needs. Half of the residents at my hospital are foreign born and trained. Perceived shortage, don't make me laugh.

There is nothing wrong with med students from other countries if they can pass muster and earn an american residency, that's irrelevant to the point

 

[762513]

There is nothing wrong with med students from other countries if they can pass muster and earn an american residency, that's irrelevant to the point

You are missing the point or being purposefully obtuse. You use the word perceived:

2.
interpret or look on (someone or something) in a particular way; regard as.
"if Guy does notperceivehimselfasdisabled, nobody else should"
synonyms: regard,look on,view,consider,think of,judge,deem,adjudge
"she was perceived as too negative"

As to imply there is no actual doctor shortage, and the only thing that stands in the way of primary care healthcare delivery are aggressive midlevels who are unsafe to provide the care they are providing (which you can't prove).

There often are not enough private insure patients to even support a physicians practice. A article on physicians in rural settings states "Even if they do hear the call of the wild, providers might find that there aren't enough patients to support a private practice. People in some rural regions are more likely to use Medicaid, the government health insurance program for the poor, which does not reimburse doctors for medical services as much as private insurance does." http://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to-rural-america/379291/

1/5 of the US population lives in rural settings. NP's are crucial to filling the healthcare gap and save lives day in and day out. Your opinion that the science is not conclusive on the question of independent practice is not nearly as important as treating chronic conditions and reducing morbidity and mortality for rural patients.

 

[deleted480308]

You are missing the point or being purposefully obtuse. You use the word perceived:

2.
interpret or look on (someone or something) in a particular way; regard as.
"if Guy does notperceivehimselfasdisabled, nobody else should"
synonyms: regard,look on,view,consider,think of,judge,deem,adjudge
"she was perceived as too negative"

As to imply there is no actual doctor shortage, and the only thing that stands in the way of primary care healthcare delivery are aggressive midlevels who are unsafe to provide the care they are providing (which you can't prove).

There often are not enough private insure patients to even support a physicians practice. A article on physicians in rural settings states "Even if they do hear the call of the wild, providers might find that there aren't enough patients to support a private practice. People in some rural regions are more likely to use Medicaid, the government health insurance program for the poor, which does not reimburse doctors for medical services as much as private insurance does." http://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to-rural-america/379291/

1/5 of the US population lives in rural settings. NP's are crucial to filling the healthcare gap and save lives day in and day out. Your opinion that the science is not conclusive on the question of independent practice is not nearly as important as treating chronic conditions and reducing morbidity and mortality for rural patients.

As NPs turn to demanding the same money as physicians (oregon) you don't get to claim that places with density too low for physicians would support NPs. They aren't "crucial to filling the healthcare gap", the simply aren't the standard for healthcare. What you are advocating is that it's better to try and wedge physicians out of these areas by lying to the public about the nurses being an equivalent option. That doesn't show any care for the rural populations at all and it's simply a lie because if the justification was truly, "we need them because rural...." then we wouldn't allow them independence anywhere but rural. It's a neat sales pitch but the end result is NPs want to live in the same nice cities that doctors do, they want the same money that doctors want, they want everyone to think they are an equivalent option despite it being untrue.

 

[VA Hopeful Dr]

There is nothing wrong with med students from other countries if they can pass muster and earn an american residency, that's irrelevant to the point

Smartest internist I've ever known was Indian born and trained - actually as a dermatologist then did an IM residency here in the US.

 

[VA Hopeful Dr]

Bold parts are more responses to you...

I did not state any opinions in that first post and asked people to provide comments on the studies. It should not be relevant for comments on these studies.

This is the type of comment I was hoping to see. I'll try to respond to your points:

1 - huge number of randomly assigned patients over a very long period of time with 100% np primary care that tracked length of visits - Better sample sizes would be good. What duration are we talking about and how did you come up with that number? Although it would ideal to use completely independent NPs, there are populations of NPs, such as in rural medicine, that receive little to no oversight. For example, NPs that have not heard back for long periods of time from their supervising physicians and are practicing independently for those periods of time. Everyone tends to over-sell how independent they are, I would need to see NPs who truly have no supervising physician (and don't work in a practice with an MD they can curbside).

2 - cost and number of tests/imaging ordered - this seems to only be important if you are comparing the exact same patient. Although this might be important for future studies, it might be important to establish can those providers provide the same results, before exploring does it cost the same (since there are issues of availability). This is why you need large numbers of patients in studies, so that variations in patients can likely end up not significant. Plus, if we take a general family medicine office of MDs and an equivalent clinic of NPs you're likely to end up with roughly the same patients at the start. You could even stratify the patients based on markers. Some of the studies do this with things like A1c or BP. You could go even further and stratify based on treatment - diabetes on orals only and diabetes on insulin.

3 - number of referrals to specialists - this would also only be valid if you were comparing the exact same patient, for example, late stage diabetes. Same as above

4 - number of patients per nurse/doctor - Are you referring to time spent per patient? Yes. An analogy I use with my patients is this: if I find the best painter in the country and give him 2 hours to paint my house its not going to look all that good. If I get any run-of-the-mill painter in my area and give him a week to paint my house it will likely turn out better than the first guy. Medical care works in a similar way. If an NP has 30 minutes per patient and an MD has 10 minutes, the NP is likely to get better results.

5 - number of support staff per nurse/doctor - I'd like to know hear more about this point. More support yields better results, this has been known for some time. Better coordination of care, better follow up from tests/xrays/referrals, and so on.

6 - cost/# of meds prescribed - again, this is only relevant to the exact same cases. Also, patient responses (disorder progression) should be compared before cost of treatment Correct, however this is one of the selling points NPs use for independent practice "we're cheaper". If that's true, should be easy to prove.

7 - all the relevant clinical outcomes without leaning on these bogus patient satisfaction surveys and pretending they are clinical. - Although it would be important to only include objective data, maybe these surveys could be somehow incorporated into the study, since we are focusing on part of a medical business model. Patient satisfaction unfortunately does matter which is why time/patient is so important



This issue is important with NPs gaining independence to practice.



Because if I am not using opinion statements, I should not have to explicitly state that I am not using opinion statements, much like I would not state that the post is written in the English language, when all the words that I used are from that language. I will add that onto the original post for clarification, but that should not be necessary.

 

[762513]

As NPs turn to demanding the same money as physicians (oregon) you don't get to claim that places with density too low for physicians would support NPs. They aren't "crucial to filling the healthcare gap", the simply aren't the standard for healthcare. What you are advocating is that it's better to try and wedge physicians out of these areas by lying to the public about the nurses being an equivalent option. That doesn't show any care for the rural populations at all and it's simply a lie because if the justification was truly, "we need them because rural...." then we wouldn't allow them independence anywhere but rural. It's a neat sales pitch but the end result is NPs want to live in the same nice cities that doctors do, they want the same money that doctors want, they want everyone to think they are an equivalent option despite it being untrue.

1. You ignored my statement of there being a physician shortage entirely; I can say I have won that debate, as it's not a debate at all.
2. You cant prove independent NP's don't provide safe care. Studies say they do. If there were even low evidence studies that found significant outcome disparities that would be much more convincing than simply stating the current studies aren't rigorous enough for your liking, even though they are performed by trained researchers.
3. NP's can demand whatever they want, they will never be compensated the same as physicians, and they should never be compensated the same. However, NP's are underpaid, and in any negotiation one demands what cannot be given (equal pay as physicians) and the result will be an increase in pay to a level at least equal to PA. It's an obvious negotiation tactic.
4. VAHopefulDoc; I agree, I have been very impressed by our foreign trained doctors, but if there wasn't a perceived doctor shortage, there may very well be less openings for them in the United States.

 

[deleted480308]

3. NP's can demand whatever they want, they will never be compensated the same as physicians, and they should never be compensated the same. However, NP's are underpaid, and in any negotiation one demands what cannot be given (equal pay as physicians) and the result will be an increase in pay to a level at least equal to PA. It's an obvious negotiation tactic.
.

in oregon, NPs got passed a law that paid NPs the same as physicians for each code and also banned private insurance from paying differently. The NPs absolutely used "we're cheaper" to get in the door and then promptly switched to "same money for same work".

 

[BlackDynamite]

Australian reimbursement for each service rendered increases as you practice more rurally. They have no distribution problem.


Sent from my iPhone using SDN mobile

 

[VA Hopeful Dr]

1. You ignored my statement of there being a physician shortage entirely; I can say I have won that debate, as it's not a debate at all.
2. You cant prove independent NP's don't provide safe care. Studies say they do. If there were even low evidence studies that found significant outcome disparities that would be much more convincing than simply stating the current studies aren't rigorous enough for your liking, even though they are performed by trained researchers.
3. NP's can demand whatever they want, they will never be compensated the same as physicians, and they should never be compensated the same. However, NP's are underpaid, and in any negotiation one demands what cannot be given (equal pay as physicians) and the result will be an increase in pay to a level at least equal to PA. It's an obvious negotiation tactic.
4. VAHopefulDoc; I agree, I have been very impressed by our foreign trained doctors, but if there wasn't a perceived doctor shortage, there may very well be less openings for them in the United States.

Ugh...

1. Its not a shortage, its a distribution problem.
2. First, crappy studies say this. Second, there are no PUBLISHED studies that say different. Nurses aren't going to publish those studies if they get results they don't like and physicians, quite honestly, have both better things to study and lack the ability to get a study past any decent IBR with the hypothesis we would want to use. We've gone over this with you before.
3. Umm, they are compensated the same in many places. In those where they are not, they are paid I believe 80% of physician rates (at least by CMS). PAs are paid the same % as NPs. If that is underpaid, what percentage is fair to you?
4. You have no clue how medical education works. We have foreign doctors because for now there are more residency spots/year than there are US medical school graduates. Its been this way pretty much forever (though that will change in a few more years I believe). It has nothing to do with any physician shortage, perceived or otherwise.

 

[762513]

1. Really?

https://www.aamc.org/newsroom/newsreleases/385506/07172014.html?version=meter+at+0&module=meter-
Links&pgtype=article&contentId=&mediaId=&referrer=http%3A%2F%2Fthehealthcareblog.com%2Fblog%2F2014%2F07%2F21%2Fthe-answer-to-the-doctor-shortage-isnt-more-doctors%2F&priority=true&action=click&contentCollection=meter-links-click

https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html

http://ushealthpolicygateway.com/vi.../impact-on-access-to-care/physician-shortage/

https://www.aamc.org/newsroom/newsreleases/426166/20150303.html
"The doctor shortage is real – it’s significant – and it’s particularly serious for the kind of medical care that our aging population is going to need,” said AAMC President and CEO Darrell G. Kirch, MD."

Now show me why you say there is not a physician shortage. I'm not being confrontational; why do all these reputable associations and organizations say one exists when you say one does not.

3. NP and PA should be compensated the same in all places, not "many places."