Apples & Oranges: Comparing Nurse Practitioner and Physician Prescribing of Psychotropic Medications for Medicaid-Insured Youths

This topic is interesting as I use to be a Psychiatric NP before becoming an MD. The study objective is: To describe psychotropic medication prescribing practices of nurse practitioners (NP) and physicians for Medicaid-insured youths in 2012–2014 in a mid-Atlantic state where NP independent prescribing is authorized. The study references that psychiatrists play a major role in prescribing medications for children with behavior/mental disorders, however, there is a shift toward utilizing the services of a variety of primary care physician specialists (e.g., family medicine, pediatrics, or internal medicine) and advanced practice clinicians such as nurse practitioners (NPs) to fill staff shortages. As I wasn’t able to obtain full access to this article without paying half a Benjamin, my commentary will be limited to the abstract and a little of the first page. A problem right off the bat is what could be considered a flawed assumption that you can use one discipline/profession to fill shortfalls in other disciplines/professions. While we all know it is true that non-physician providers (NPPs) are in fact being used in places to fill these shortfalls, it doesn’t make it right. Nor is the act of doing so justification for doing it. These last two sentences are topics for other blogs. Back to the study, I’m not sure what the hypothesis is or even would be. I do know that my own prescribing as a Psych NP is different from prescribing as an MD. I’m much more cautious, trepid, and comprehensive. Maybe that’s the point, that there are differences in prescribing patterns among NPs and physicians. 

            The study analyzed 1,034,798 dispensed psychotropic medications prescribed by NPs and physicians for 61,526 continuously enrolled Medicaid-insured youths aged 2-17 years. I’m not sure why the inclusion criteria included children as young as 2? That to me would require some serious expertise in child psychiatry. As such can you really compare apples to oranges, doctors to nurses, motorcycles to care etc – you get the point. This also brings up another point – are the authors comparing doctors practicing medicine to nurses practicing nursing? Or doctors practicing medicine to nurses practicing medicine? Perhaps this is another flawed assumption, that nurses practice medicine. Or maybe that’s the big lie, that under the guise of practicing nursing, NPs are actually practicing medicine? Regardless, the results of the study are as follows:

  1. 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%)
  2. 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%)
  3. Psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively)

I was not able to ascertain the statistical significance of the change in prescribing patterns among provider types. Where the results show that NP prescribing psychotropics has increased and physician prescribing has decreased, the study concluded: The quality of NP prescribing practices deserves further attention.

REFERENCES:

  1. Yang BK, Burcu M, Safer DJ, Trinkoff AM, Zito JM. Comparing Nurse Practitioner and Physician Prescribing of Psychotropic Medications for Medicaid-Insured Youths [published online ahead of print, 2018 Mar 13]. J Child Adolesc Psychopharmacol. 2018;10.1089/cap.2017.0112. doi:10.1089/cap.2017.0112

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

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