APRNs Provide Care Equal to Doctors, Review Concludes

Advanced practice nurses can provide care with patient outcomes that are at least as good as, and in some cases better than, care provided by physicians, according to a literature review by Johns Hopkins researchers.

"The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States," wrote Julie Stanik-Hutt, associate professor of nursing at Johns Hopkins, and colleagues.

That recognition "could help address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care."

The paper, published in Nursing Economic$, reviewed 107 reports that compared outcomes in treatment of several diseases and conditions, as well as patient satisfaction in care provided by nurse practitioners, certified nurse midwives, and clinical nurse specialists.

The results should influence healthcare policy in paving the way for an "expanded role" for APRNs in healthcare systems and should be incorporated to the fullest extent possible," they wrote.

APRN-provided care "should be expanded to additional settings and populations," restrictions on APRN practice and reimbursement should be modified to test new models of care, and APRNS should be "used to the full extent of their scope of practice," the authors wrote.

Also, billing data should indicate the actual care provider is a nurse practitioner, certified nurse midwife, clinical nurse specialist, or certified registered nurse anesthetist.

For example, the researchers found five studies in which there was a "high level of evidence" that care provided by nurse practitioners achieved glucose control levels comparable to care provided by physicians, and three studies that had similar findings for patients being managed for lipid levels.

They found studies showing high levels of confidence that outcomes of nursing care were similar to outcomes of physician care in blood pressure control, urgent or emergency care visits, rates of hospitalization and rehospitalization of patients in nursing homes and ambulatory care settings, and in mortality rates.

For certified nurse midwives, the report found high evidence that care was equal to that provide by physicians in rates of cesarean section, and in rates of low Apgar scores.

In a few categories the researchers found only moderate evidence that care was equal to physicians. For example, three studies of initiation of breast feeding found only moderate evidence that nurse midwife care was comparable to that provided by physicians.

The literature analysis drew many of the conclusions contained in a lengthy Institute of Medicine report last October regarding expanding the purview of the nursing profession to improve access to care as well as quality.

The Johns Hopkins report focuses attention on a controversial topic because several physician groups, including the American Academy of Family Physicians, the American Osteopathic Association, the American Academy of Pediatrics and the American Medical Association have opposed certain expansions of advanced practice nurses to provide types of care normally reserved for physicians or osteopaths.

In a strongly worded letter to the New England Journal of Medicine Jan. 20, leaders of those four groups took issue with the IOM report, saying its "recommendations are not sufficiently evidence-based."

They added that "80% of patients expect to see a physician when they come to the emergency department, with more than half of those surveyed willing to wait two additional hours to be cared for by a physician."

"Although nurses are critical to the healthcare team, there is no substitute for a physician's education and training," they wrote.

In states where nurses and physicians practice independently, "physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped to solve the problem of shortages in rural areas," they wrote.

Last year, the California Medical Association filed a lawsuit against the state's governor for using a Medicare opt-out provision to allow certified registered nurse anesthetists to administer anesthesia without physician supervision. The CMA argued that CRNAs do not have as much training as physicians, and cannot provide care as safely, but the court did not agree. Two months ago, CMA attorneys said had not decided whether to appeal.

The AMA and CMA did not respond to requests for comment.

Maureen Cones, senior nursing practice counsel for the American Nurses Association, said in a telephone interview Tuesday that advanced practice nurses are still fighting for the right to provide care to the full scope of their training and education, especially in many states where physician groups, licensing boards or legislation have limited their practice.

"Particularly since 2009, there have been concerted efforts to limit authority for advanced practice registered nurses to participate in the healthcare system to their full extent...because scope of practice rules vary state by state because of states rights issues," she says.

For example, there are limits to practice in Arkansas, California, Colorado, Indiana and Louisiana for such functions as the ability to prescribe medications or practice independently. In Iowa, she says, the Iowa Society of Anesthesiologists and the Iowa Medical Society are in court seeking to prohibit APRNs from using fluoroscopy.

Fluoroscopy is an X-ray like strategy to help visualize procedures so the practitioner knows lines are being placed in the appropriate location for pain mediation or cancer care.

"That's important because in Iowa, there are a lot of rural areas where folks who don't have access to fluoroscopic services provided by APRNS won't get the care they need," she said.

In its conclusion, the Johns Hopkins authors wrote that "APRNs, in partnership with physicians and other providers, have a significant role in the promotion of health. American healthcare professionals will have to move forward with evidence-based and more collaborative models of are delivery to promote national unified health goals."