Another Look: Nurse Practitioners, A Solution to America’s Primary Care Crisis

Just sitting here on a lovely Sunday evening catching up on some writing, relaxing, and decided to take another look at an article I’ve written about before. In this article, the bias is blatant. The article reports “the studies described in this report consistently show that NPs are significantly more likely than primary care physicians to care for vulnerable populations.”  It references more studies where it reports “Our studies showed that beneficiaries who received their primary care from NPs consistently received significantly higher-quality care than physicians’ patients in several respects.” However, the article then reports limitations “some of these studies analyzed a limited number of clinical conditions, did not adequately control for patient-selection biases and disease severity, and assessed quality measures over brief time periods, which makes it difficult to generalize results to broader populations.” Thus, the article attempts to conclude NP’s superior over physicians while ignoring the limitations and poor methodology. 

            The article has an appendix with all the referenced studies. The first one on the list is A. B. Hamric et al., “Outcomes Associated with Advanced Nursing Practice Prescriptive Authority,” Journal of the American Academy of Nurse Practitioners 10, no. 3 (March 1998): 113–18. This article is 22 years old. It measured data from only 33 NPs. Patient satisfaction was one of the outcome measures. I wasn’t able to obtain access to the full article, so to be fair, I can’t really conclude on the quality of it, however the abstract has red flags. 

            Another referenced study Maarten C. Kuethe et al., “Nurse Versus Physician-Led Care for the Management of Asthma,” Cochrane Database of Systematic Reviews 2 (February 28, 2013): 1–35,http://cochranelibrarywiley.com/doi/10.1002/14651858.CD009296.pub2/abstract;jsessionid=19F6FA5D08C31517B746428D5DB1087A.f02t01 . This reference is a systemic review as well. Interesting that the original article, a systemic review references another systemic review. This review was of “the effectiveness of nurse-led asthma care provided by a specialized asthma nurse, a nurse practitioner, a physician assistant or an otherwise specifically trained nursing professional, working relatively independently from a physician, compared to traditional care provided by a physician.” This study was based out of Amsterdam. This review was comprised of 5 studies for a total of 588 adult and children patients. They referenced the 5 studies as having “good methodology” but annotated that “it is not possible to blind people giving or receiving the intervention to which group they are in.” Thus not blinded randomized control trials of intervention vs placebo. The studies included in this review were reported as randomized control trials, but it seems that the nurse-led group was the intervention group and the physician management group was the control group. It seems asthma exacerbation and asthma severity were outcome measures and the review found “no statistically significant difference in the number of asthma exacerbations and asthma severity” after treatment. Follow up ranged from 6 months to 2 years. It does not reference the amount of asthma treatment prior to the studies and one of the conclusions was based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. Who was managing the care prior to the studies in the review? 

Let’s look at one of the studies in this review. Lost yet? Recall that this blog pertained to systemic review Nurse Practitioners, A Solution to America’s Primary Care Crisis which referenced another systemic review Nurse Versus Physician-Led Care for the Management of Asthma. Here’s one of the studies the 2nd review referenced: “Pilotto LS, Smith BJ, Heard AR, McElroy HJ, Weekley J, Bennett P. Trial of nurse-run asthma clinics based in general practice versus usual medical care. Respirology 2004;9(3): 356–62.” (https://pubmed.ncbi.nlm.nih.gov/15363008/). The aim of this study was to assess the ability of nurse‐run asthma clinics based in general practice compared with usual medical care. “The main outcome measure was the St George’s respiratory questionnaire (SGRQ), from which quality‐of‐life scores were used to assess therapeutic benefit.” It wasn’t clear as to in these nurse-run clinics, what asthma guidelines or protocols they were following, or if there was physician oversight of these clinics. Patients were followed for 6-9 months. It wasn’t clear on the recruitment of patients into the clinics or prior asthma care the patients had prior to coming to the clinic. The study concluded: “Nurse‐run asthma clinics based in general practice and usual medical care were similar in their effects on quality of life and lung function in adults.” However, the article also concluded “These findings cannot be generalized to hospital outpatients and other clinics that manage more severe asthmatic patients.” 

            So………….. I’ll leave it there.

Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant. 

  2 comments for “Another Look: Nurse Practitioners, A Solution to America’s Primary Care Crisis

  1. Bridget Reidy
    September 7, 2020 at 1:42 pm

    No statistically significant difference is not the same as no difference. Statistics 101. Yeah look for asthma exacerbations in a mild asthma group over a short period of time is the perfect way to use that kind of manipulation of logic.

  2. Kurt
    September 2, 2020 at 11:24 pm

    I had an NP for 20 years as assigned by my employer and she was in the same office area as me. I was in a standard Pri care practice, office, hospital and call whereas she did just the office side. Did a great job but she came to it in a roundabout way. Got married at 19. Got divorced a few years later. Worked her way through nursing school and went to work for an Oncology group for 8 years. Remarried to a great school teacher guy and decided on the masters. The Oncology group wouldn’t support her in her quest for NP status so she quit as she and her husband could get by on his salary. Got her masters and came to work at the clinic where I was at and she was sort of assigned to me. Incidentally, the Onc group caught wind of her graduating from NP training and approached her to hire her back. She said, ”No thank you.” As they didn’t support her in her quest for education.
    We hit it off well as we both had a “lusty” sense of humor and both went through “hell” in our training.
    Being in the same office area, she would hit me up on the difficult patients for my input but still took care of the run-of-the-mill routine stuff. She learned from me too like the gentamicin trick. 120mg. in each butt cheek to keep someone out of the hospital with COPD along with orals, pulmonary toilet and home nebulizer therapy. A one time dose of gent with someone who had a depressed GFR usually didn’t dork’em that much but if they had known CKD, we’d adjust the dose downward.
    Another plus as my practice shifted towards geriatrics, is a lot of the older ladies felt more comfortable with a woman doing the pap smear. I could turf them to my NP as she was o.k. with it, the patients were happy with it and I was fine with it. If I wanted to spend all my time between women’s legs, I would’a been a groinocologist for chrissakes!!
    Collaboration is the only WAY to go here with NP’s. Period.
    We had a blast together. She retired a bit earlier than me as she was older but now I’m done (retired) and really happy to be out of primary care. My NP told me she wouldn’t want to be without a doc to talk to. If they go independent they will find out how hard it is and “their” malpractice rates will go through the roof.
    Incidentally, my NP found the proverbial pheochromocytoma in a 32 year old female by ordering the appropriate VMA’s, metanephrines etc. I was aghast! :-). I retired without ever finding one directly although I ordered a pile of tests for them.
    I started out in a surgery residency and saw a few of them in the big university institutions so alpha and beta blocking them was “pounded” into my head before surgery. I was not unfamiliar with it. I had one guy I swore who had it but after a million dollar workup, nada, nothing, couldn’t see anything on a scan. I had him on a butt load of meds and the nephro diddled with them a little bit after I referred him to them and eventually the the BP went down. Patient might have been extraordinarily salt sensitive and once he gave that up, BP was better controlled with fewer meds. So be it.

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