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NPs, MDs disagree on scope-of-practice changes

Thursday May 16, 2013
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Primary care physicians and nurse practitioners significantly disagree about some proposed changes to the scope of nurse practitioners’ responsibilities, according to a study.

Specific points of disagreement revealed in a survey of healthcare providers centered on appropriate leadership roles for NPs, reimbursement levels and the overall quality of services they provide, reported investigators from Massachusetts General Hospital and the Institute for Medicine and Public Health at Vanderbilt University Medical Center.

“We were surprised by the level of disagreement reported between these two groups of professionals,” Karen Donelan, ScD, EdM, the study’s lead author, said in a news release. “We had hypothesized that, since primary care physicians and nurse practitioners had been working together for many years, that collaboration would lead to more common views about their roles in clinical practice.

“The data reveal disagreements about fundamental questions of professional roles that need to be resolved for teams to function effectively,” added Donelan, of the Mongan Institute for Health Policy at MGH.

At a time when the United States healthcare system is facing both an increasing demand for primary care services and a worsening shortage of primary care physicians, one broadly recommended strategy has been to increase the number and the responsibilities of NPs. In 2010 an Institute of Medicine committee stated that "advance practice registered nurses should be able to practice to the full extent of their education and training" and NPs should be able to admit patients to hospitals and hospices, lead medical teams and medical homes and receive reimbursements similar to what physicians receive for providing those services.

Little data has been available on the roles played by NPs in primary care and how they differ from those of primary care physicians, the authors noted. The study, published in the May 16 issue of the New England Journal of Medicine, was designed to assess those roles and how expanding them might affect the healthcare system. The survey was mailed to a national random sample of nearly 2,000 primary care clinicians, evenly divided between physicians and NPs. Responses were received from 467 NPs and 505 physicians.

Majorities of both groups — 96% of NPs and 76% of physicians — agreed with the IOM recommendation that nurse practitioners "be able to practice to the full extent of their education and training," and 76% of NPs reported they were doing so. Majorities also agreed that increasing the supply of primary care NPs would improve the timeliness of and access to care, and respondents working in collaborative practices indicated both professions provide a wide range of services in their practices.

But the survey revealed significant disagreements on specific recommendations:

• 82% of NPs believed they should be able to lead medical homes, but only 17% of physicians agreed;

• 64% of NPs agreed they should be paid equally for providing the same services, compared with only 4% of physicians;

• When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do NPs during the same type of primary care visit, 66% of physicians agreed and 75% of NPs did not agree;

• 60% of NPs in collaborative practices indicated they provided services to complex patients with multiple conditions, while only 23% of physicians in such practices responded that those services were provided by NPs;

• The two groups disagreed significantly regarding whether an increase in the supply of NPs would improve patient safety, the effectiveness of care and health costs, with a third of physicians responding that such an increase might have a negative effect on safety and effectiveness.

“It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other’s contributions,” Peter Buerhaus, RN, PhD, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt and a co-author of the paper, said in the news release.

“I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce.”

The investigators noted the need for more analysis of the economic implications of expanding NP roles and responsibilities, as well as the contribution of NPs to the care of complex patients.

“At this stage, discussion is critical to finding points of agreement,” Buerhaus said. “Several states have workforce commissions that might serve as a forum for primary care physicians, nurse practitioners, payers and even patients to discuss these issues.”

Read the study abstract: www.nejm.org/doi/full/10.1056/NEJMsa1212938.


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