Fletcher CE (Center for Practice Management & Outcomes Research)
Copeland LA (VERDICT)
Reeves PJ (VISN 11 Headquarters)
Lowery JC (Center for Practice Management & Outcomes Research)
To conduct a pilot study evaluating the complexity of care provided by nurse practitioners (NPs) in comparison with physicians to determine the appropriateness of NPs scope of practice and the collegiality of the nurse/physician relationship.
Physician and NP primary care providers in VISN 11 were surveyed in a VISN-wide pilot study; 63 (70%) NPs and 67 (36%) physicians responded. Survey questions included perceived scope of NP practice and evaluation of collegiality between NPs and physicians. Administrative data were pulled only on patients with hypertension or diabetes seen as outpatients (June 2003-May 2004; n=115,568).
Physicians (92%) and NPs (90%) rated the NP/physician relationship highly or usually collegial. When asked if NPs are expected to perform beyond their scope of practice, 50% of physicians vs. 28% of NPs were somewhat to extremely concerned (p=.01). When asked if NPs actually perform beyond their scope of practice, 47% of physicians vs. 21% of NPs were somewhat to extremely concerned (p=.01). Nevertheless, analysis of secondary data indicates that the complexity of care provided by NPs is not significantly greater than that provided by physicians. Patients receiving their primary care principally from NPs vs. physicians averaged statistically significantly fewer visits for primary, specialty, surgery-related, and psychiatric outpatient care. Physicians’ patients had significantly higher creatinine values 4.9% vs. 4.0% but indistinguishable A1c values. Means for the age-adjusted Charlson scores were 3.3 for NPs and 3.6 for physicians. Somewhat more NP patients had high blood pressure (40% vs. 38%) and they were less likely to be on cardiovascular agents (84% vs. 86%). Although statistically significant, these differences were unlikely to have clinical significance.
The use of NPs has been encouraged by VA policy to supplement overburdened physicians. Preliminary study findings suggest that NPs are providing appropriate, comparable primary care for patients with diabetes/hypertension.
The use of NPs to provide primary care to veterans is a major policy shift previously unstudied. This pilot study supports the use of NPs to provide primary care for veterans.