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.

230590cookie-checkAnother Look: Nurse Practitioners, A Solution to America’s Primary Care Crisis