Editor’s Note: The content of this blog was composed by a member of Physicians for Patient Protection who wishes to remain anonymous for career protection. As background, The American Association of Nurse Practitioners (AANP) is a professional organization representing Nurse Practitioners (NPs) and students. Some of its major advocacy work is in the area of practice autonomy for NPs, as they push for independent NP practice in all 50 states. AANP uses its position papers to educate its members and legislators. One of their position papers is critically evaluated in this blog.
Grave Concerns about the Misrepresentation of Science
I began a project to review the original research articles in the annotated bibliography of the American Association of Nurse Practitioner’s (AANP) position paper, “Quality of Nurse Practitioner Practice”. I wanted to investigate their claim that “Nurse Practitioner care is comparable in quality to that of their physician colleagues.” I quickly realized that the research synopses provided by the AANP were incredibly misleading, based on the articles presented.
Brief Overview of Problems
I will provide a brief overview of some specific misleading claims made by the AANP. For example, AANP cites studies in which physicians were involved in the patient care, yet they attribute the benefit to Nurse Practitioners (NPs), even when it isn’t clear whether it was the NP or the physician who performed critical tasks for the patient.
AANP also cites studies that are too small to draw any conclusions.
AANP cites such studies as showing definitive proof of their equivalence claim by either omitting key details or blatantly misinterpreting the statistics, which seems highly unethical.
Deeper Dive into Specific Studies
The AANP concludes that the study, Ettner et al., 2006, found that a “physician-NP team achieved significant cost savings … compared to the control group, while the outcomes … were comparable”, implying that a team with an NP had equal outcomes with lower cost. They conveniently omit that the “physician-NP team” intervention added additional physicians to the team, along with NPs (2 attending physicians, 4 resident physicians and 6 interns vs. 2 attendings, 4 residents, 6 interns + physician director + extra attending physician time + 2 NPs [working 27% of hours/week]). A team with more physicians and with NPs only working 27% of the work hours was used to claim comparable outcomes and “significant” cost savings over a team with all physicians.
Similarly, from Gracias et al., 2008, the AANP concludes “that clinical practice guideline adherence was significantly higher among patients belonging to the NP team.” The AANP neglects to mention that this study was designed to test a new ICU treatment model, and that NPs didn’t replace physicians in any way. In the old model, an intensivist physician and a surgeon both placed patient care orders with the help of resident physicians. In the new model, the intensivist physician was placed in charge, while the surgeon provided consultation. An NP was added to the team of resident physicians, and this physician-led team was called the “NP team.”
Both of these studies added NPs to a physician-led treatment team, but also changed much more than just adding an NP or two. The AANP reports the results as if benefits could be definitively attributed to adding NPs. They mislead the public by omitting the physician leadership, and by omitting major changes in team process which may have driven the noted benefits.
Comparable, Superior, or Neither? Statistics 101
The AANP presents several articles using the word “comparable” to describe care outcomes of NPs and physicians, including the following publications: Borgmeyer et al., 2008; Cooper et al., 2002; Lenz et al., 2004.
The AANP’s interpretation of the results of these studies as “comparable” is based on a misleading and incorrect interpretation of statistics. These studies were designed to test whether one of the groups was superior to the other, but they failed to find superiority.
A failure to find superiority does not mean that the groups are comparable. The AANP should know better, but the general public, many of whom have no statistics training, may not understand this distinction.
Confounded Groups and Poor Statistical Reporting
Similarly, Sackett et al., 1974, is reported as having “comparable” outcomes between NPs and physicians; however, this study is replete with flaws making it impossible to accurately interpret:
- The statistical tests used by the investigators are not reported.
- There are 3 primary “health status” outcomes, but there is no statistical correction made for these multiple comparisons.
- Beta is not reported for the mortality outcome, meaning that no conclusion of equivalence can be justified.
- Physicians are reported to have seen patients at about 1/3 of the NP visits during the last two months of the study period, but the number of NP visits where a physician was involved prior to that was not reported.
Obviously, having a physician involved in the patient care, rather than just the NP, confounds the data and makes it impossible to conclude anything about NP care.
Sacket et al., 1974, cannot be a legitimate and honest basis for claims regarding NP independent practice. In addition, in 1974, NPs were all working directly with physicians. There was no independent NP practice in that decade.
Meta-Analysis Reveals Flaws in AANP Reasoning
The AANP states that Laurant et al., 2006 found care between nurses and physicians were “equivalent.” However, that Laurant meta-analysis found that “only one study was powered to assess equivalence of care”, and it was this one: Lattimer et al., 1998, a study of nurses (not NPs) providing first phone contact after-hours, with a physician immediately available and accessed for approximately half of the phone calls.
We learned from Lattimer that nurses can handle patient phone calls after-hours, with physician back-up, but learned nothing about the quality of NP care from that study, despite AANP claims to the contrary.
More Confounding of Data
The AANP presents Mundinger et al., 2000, a randomized controlled trial of NP vs. physician primary care, as finding “comparable” health outcomes between the two groups. Although this article claims to be adequately powered to find meaningful differences in self-reported health outcomes between physician and NP primary care, confounders make the results of this study uninterpretable.
The authors later even critique their own prior research. In a follow-up paper from the same two lead authors (Lenz, Mundinger, et al., 2004), the authors critique the method of analysis used in the original paper: “approaches, such as an intention-to-treat analysis including all randomized participants, would have increased the statistical power. However … such analyses would have greatly favored the null hypothesis [NP/Physician equivalence] … by including participants who had changed practices during the study.” This paper is also confounded by the fact that the patients all received emergency or urgent medical care on the day of their baseline survey, almost certainly cared for at that time by a physician.
A Challenge to Do Better
I challenge the AANP to present only articles that support their claim that “NP care is comparable in quality to that of their physician colleagues” in a manner that is statistically justified. These trials should be randomized and controlled with equivalent patient populations in both treatment groups. NPs alone should be responsible for diagnosis and treatment pertinent to the outcomes studied. If specialist/emergency/hospital care is made, it should be accounted for as a confounder. If the trials are designed as superiority trials, they should only be touted if a finding of superiority is justified. For claims that care is “comparable,” the trial should be designed as an equivalence study and adequately powered. If multiple primary outcomes are identified, multiple comparisons should be corrected for in the statistical analysis. If a finding is in fact justified, the external validity should be clearly identified, including the patient population and setting of care.
If the AANP cannot find and show these studies, I urge them to fund these studies through a neutral intermediary and retract their misleading statements regarding NP and physician equivalence.
–A Physician (Scientist) for Patient Protection
1. Training for NP or PA simply cannot equate to the premed science background and 4 years of additional science background that continues throughout medical school.
2. Not to put too fine a point on it, nor to detract one iota from the skilled, conscientious and talented nurses of all advanced degrees I have had the privilege to work with over the past 40 years, but the selection criteria for admission, at least in my era, was vastly different. Approximately 1 out of 10 applicants were admitted to medical school.
3. Nursing, at least in my experience, is oriented to protocol and implementing treatment. Medicine is oriented from the outset toward evaluation of a sometimes massively complex set of variables to arrive a first a diagnosis, then a treatment plan, then an ongoing evaluation of that treatment plan, and constant adjustment of that treatment plan. All three phases of “evidence based medicine”, not just the first phase where we can all argue about what the “data” says.
4. There is no question that there are many nurses, advanced degree nurses, NPs and others who have more than adequate brain power, a reasonable percentage of whom probably would test higher that several physicians on a basic IQ test. That is not the point.
5. There is no substitute for background, basic science, clinical science and incorporating that into ongoing treatment. Coupled with overall responsibility.
6. I could personally care less whether advanced degree nurses have independent treatment authority or not. It has been my experience, working with both NPs and PAs, excellent individuals, that their expertise was at significantly lesser level than physicians overall. And especially compared to experienced physicians. The above points regarding limitations arising from the basic educational differences between nursing and medicine, are echoed by my ex-wife, an excellent CRNA in her day, now a highly respected attorney.
7. It does seem that, if advanced degree nurses have this independent authority, they must be charged with the same independent responsibility for accuracy, skill and outcome as physicians. It is not difficult to come up with an integrated measuring algorithm related to this. No different than physicians who come up against a disease entity that is beyond their area of expertise, and they are ethically obligated to refer to someone else who has the needed expertise.
8. This internecine conflict between the two classic professions that have been historically linked in medical care, is carefully cultivated by the administrative entities who are locked in massive large battles with each other over massive amounts of the national budget. Nurses, doctors, pharmacists, other health care professionals and most of all, the patients, are just pawns on a massive game board where massive entities are very skillfully competing with each other for massive dollars. Both nurses any physicians are inexorably going to get screwed by these entities. All will increasingly become tiny cogs in the massive corporate and governmental machinery designed to carve out the maximum money they can from the already bloated health care dollar. Whether it is Big Pharma, Big Insurance, Corporate medicine, whatever. For example, Blue Cross wrote the ACA (Obamacare). And, through wholly owned subsidiaries, they administer Medicare. They write the rules. They then carry out the rules. And nurses, doctors pharmacists, others all squabble with each other in these fabricated turf wars, while they and the patients get the shaft. Those of you crying for “data” only need to look at the massive increase in administrator numbers and administrator salaries compared to physicians and nurses, And look at the profitability and massive multi million dollar compensation for the corporate leaders and stockholders. To say nothing of the political contributions that put your representatives in their pockets (for example, Big Pharma’s government influence budget is twice that of the military industry). Don’t look too close at the VA decision makers and who influences it, all nice talk about how much they care about vets notwithstanding. As Jim Hightower stated so succinctly, “They don’t lobby the government. They are the government.” Not a penny of the above bought a bandaid, made a diagnosis or administered a bit of care or treatment.
9. It is high time all those professionals involved in health care became really angry, along with their patients, and demanded that health care authority return to those who have today been left with the responsibility but have had the authority slowly carved away by the massive moneyed interest. Disruption and protest is all that moves them. They knew what they were doing to nurses and doctors alike from the outset, before you did. Nurses, it seems have a head start over docs on getting together collectively, but we are all far behind where we need to be. Let’s put aside the differences, squabbling, and nastiness, that we have all been suckered into engaging in, and focus on the real problem. Out of control profit mongering by huge entities not directly involved in caring for patients.
I couldn’t agree with you more about patients and providers being used as cogs in a system to generate money rather than health.
If find this article troubling in that it’s a hatchet job on the AANP position statement rather than a review of the current literature.
This blog is a critical review of the exact literature cited by the AANP to support NP independent practice. We didn’t cherry-pick which articles we reviewed–we reviewed all the articles currently cited by the AANP. We’re happy to review more, of course. And we stand by our assessment that the literature absolutely does not support independent practice for NPs. It supports NP care in a physician-led team environment.
@WH — extremely well-said and balanced comments! Experienced RN here and have always been lucky to work with a diverse team of professionals. Most of the NPs I know were RNs for 20+ years before getting advanced degrees, and I do think this helps their clinical judgment, although I know it generally cannot compare to the training and experience of a physician working in the field for the same number of years.
I have come across a newer cadre of NPs who only worked a few years as an RN, or even worse, went straight through BSN followed immediately by NP without any sort of meaningful clinical experience. I find those to be especially offensive — like how are you going to give me orders when you hardly know what you are doing yourself? I don’t mind as much with interns and residents as they are obviously still learning, and we can call their supervisory team for questions/issues if things get complicated.
Personally, I never felt comfortable to pursue NP credentials because how could I ever sleep at night, knowing it was just ME making all these treatment decisions and prescribing medications and all the rest? I would probably still think of myself as a nurse even if I went to medical school — if I did, at least I would have my additional 3-5 years of formal schooling and perhaps another 15K hours of supervised clinical training to lull me back to restful sleep.
It’s a tough job and the only way we can get through is together — each working in safe, smart and suitable roles. I think hospital administrators and insurance companies owe much of the blame here, for sucking up the lion’s share of any possible revenue and forcing us into roles to “save money” so they can continue to play their game.
My GI group which is a part of a large medical system recently hired an NP who was brought in under the guise of a skilled person to help us eliminate some of the burdensome, time consuming tasks that keep us in the office till all hours. The NP quickly assumed responsibilities that were not in her purview. She started seeing patients, initially restricted to colon ca screening visits and subsequently she began seeing GI consults. This was supported by management and it became abundantly clear that they liked poorly executed care more than the care of the trained gastroenterologists on the staff. This was a purely monetary decision as an NP makes an average salary of 110K. Physicians make 3 or more times that amount. This trend is sweeping the nation and physicians are allowing it to happen.
If my NP could pass the GI boards, I would feel more comfortable having her see patients.
As a Pharmacist, I cringe at the idea of an NP treating me. I demand a Physician (MD or DO) every time. No substitutes. Everyone needs to stay in their own lane. And by everyone I mean NPs, PAs, Pharm.D.s as well.
I am sorry, who wrote this article (PPP Admin) and what are your research credentials? I’d think a “physician scientist” would expand their literature review beyond the reference list of the AANP position paper. Give these a read and perhaps do an actual literature review.
Perhaps give Laurant et al., 2018, a gander
~ A concerned Nursing Doctoral Student
We hope your nursing doctoral program will teach you to evaluate literature more critically. Laurant et al., 2018 has conclusions that aren’t supported by the very literature reviewed in their meta-analysis. From that paper: The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow‐up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor.
So their conclusions that NPs are as good as (or better) than physicians, are completely invalid.
That BMJ article you cited is from 2002, when all NPs were working with physicians–no independent NPs in those studies. Oh, and the studies showed that NPs ordered “more investigations” than physicians. They ordered more tests, unsuprisingly. You might want to remove that article from your arguments for NP independence.
As a physician scientist I read the studies myself to interpret them.
The alternative is to do what a Nursing “Doctoral” Student does, and plagiarize someone else’s conclusions instead of making my my own.
I guess since you’re plagiarizing MDs assessments and plans in your clinical care, parroting the results section of an abstract is an expected next step.
This is an excellent review.
Can I have permission to download, copy, and reproduce ?
TED SWITZER, MD, FACEP
Absolutely! Thank you for sharing it far and wide.
I agree wholeheartedly with the PPP stance of NP’s not being qualified to perform the same duties as physicians! As a 25-year veteran of hospital case management, I have observed this transition toward hiring the “cheaper” NP’s in an attempt to save money for the healthcare system. However, the NP’s consult numerous specialty physicians and run every single test under the sun which, in my opinion, is MORE expensive and a waste of healthcare dollars.
Additionally, in Borgmeyer et al., 2008, the study was of about 60 pediatric patients admitted for asthma exacerbation. Quality outcomes consisted of 7-day readmission, LOS, and cost. The NPs were compared to BRAND NEW INTERNS. There were no significant differences. NPs could not even demonstrate improved outcomes over brand new interns in their own cited study.
I’m so sick of hearing a bunch of whiners complain about NPs. You are just impeding progress of a profession. If you want more regulation, stop complaining and help NPs get there.
Yea, we tried. Your program by large rejects all attempts of extended education in graduated nursing education, standardized education, and harsher regulation and criteria for the profession as a whole. “Will limit patient access” was the answer to our suggestions I believe. I don’t know what to tell you. NP as a profession has decided to not listen to physician feedback to foster any improved relations.
Thank you for debunking the false equivalence in these poorly designed or poorly interpreted studies by NP lobby.
I also want to understand why we even try to compare the ‘hours’ of education/training. The time we, as physicians, spend in learning and training is not similar to how RN spends when she is on NP track. As someone put it, 5000 hours as a flight attendant cannot be compare of even 500 hours of a practicing pilot.
Secondly, If the knowledge of an NP is so superior and the corporate/legislator’s greed so intense to circumvent the physician shortage by fielding substandard ‘providers’, why can’t we have them write the same exams? Let them write the same shelf exam, USMLEs and board exam before allowing them to practice in a team, let alone independently, which they can if they can clear the exams and are appropriately trained under supervision.
By asking for more regulations, learning and training, the allegation of physicians delaying patient’s access to healthcare by NPs is not only laughable but cruelly discriminatory to the patients who do not have healthcare literacy to understand the difference in care models.