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Do physicians deliver better care than Advanced Practice Registered Nurses?

The media sometimes suggests that physicians deliver better care than Advanced Practice Registered Nurses (APRNs). Is that true?

Not according to most scientific studies, which have found that care by APRNs is as good as or better than that of physicians.

Some recent press articles have openly disparaged or devalued the care of APRNs relative to that of physicians. And the government's slogan for their "Take Your Loved One to the Doctor" media campaign completely ignored APRNs.

However, the following studies and articles show that the care provided by APRNs merits at least as much respect as that of their physician counterparts.

 

Eighteen years of studies show that APRNs do it better

August 2011 -- A metaanalysis just released in Nursing Economic$ stretching over 18 years compared care provided by advanced practice registered nurses (APRNs) to care provided by physicians. Care was compared in 24 different categories.

APRNs performed equal to physicians in 13 categories.
APRNs performed better than physicians in 11 categories.
Physicians performed better than APRNs in zero categories.

The categories in which APRNs outperformed physicians:

For Nurse Practitioners:

lower blood sugar levels
lower serum lipid levels

For Certified Nurse Midwives:

lower C-section rates
fewer epidurals
less analgesia
better breastfeeding rates
more VBACs (vaginal births after delivery)
fewer NICU admissions
fewer episiotomies
fewer perineal lacerations after delivery
lower rate of labor induction and augmentation

Clinical Nurse Specialist (CNS) augmented care was measured in 4 categories and found it provided:

fewer complications
lower cost care
shorter length of stay

Study authors included Robin P. Newhouse, Julie Stanik-Hutt, Kathleen M. White, Meg Johantgen,
Eric B. Bass, George Zangaro and Lily Fountain, Donald M. Steinwachs, Lou Heindel, Jonathan P. Weiner. See the full study...

 

APRN care is better. International Meta-anlysis

Alba DiCenso, RN, PhD, Research comparing care provided by APRNs to that of physicians. 468 papers reviewed (all Canadian papers of any type or date) and international review papers 2003-2008.

ACNPs (Acute Care Nurse Practitioners) (18 Randomized Control Trials)
US: 10, UK: 6; AU: 1, CA: 1

Health Status Quality
of Life
Quality
of Care
Patient Satisfaction Provider Satisfaction Cost Length of Stay

Improvement

5 0 0 5 1 2 2

Decline

0 0 0 0 0 0 1

No difference

7 1 7 2 1 2 2

 

PHCNPs (Primary Health Care Nurse Practitioners) (28 Randomized Control Trials)
US: 15, UK: 8; NE: 2, CA: 3

Health Status Quality
of Life
Quality of Care Patient Satisfaction Provider Satisfaction Cost Length of Stay

Improvement

7 0 0 6 0 2 1

Decline

0 0 0 0 0 1 0

No difference

15 2 2 5 1 1 0

 

CNSs (32 Randomized Control Trials)
US: 16, UK: 11, CA: 2, Other: 3

Health Status Quality
of Life
Quality of Care Patient Satisfaction Provider Satisfaction Cost Length of Stay

Improvement

15 5 2 4 0 9 5

Decline

0 0 0 0 0 0 0

No difference

8 4 0 3 1 4 1

Data courtesy of author. Research presente by Dr. DiCenso at the XV International Nursing Research Conference.

 

Patients co-managed by APRNs receive much better care than when managed by physicians alone

June 2013 -- Patients 75 and over with at least one of the following conditions were treated either by an APRN/physician team, or by a physician alone.

Condition treated in 1,084 patients over 75 years of age Co-managed by APRN and physician team, percentage of recommended care received Managed by physician alone, percentage of recommended care received
falls 80% 34%
urinary incontinence 66% 19%
dementia 59% 38%
depression 63% 60%

See Journal of the American Geriatrics Society, 2013 Jun;61(6):857-67. Effect of nurse practitioner comanagement on the care of geriatric conditions. Reuben DB, Ganz DA, Roth CP, McCreath HE, Ramirez KD, Wenger NS, at the Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA.

 

"Study: No Problems if Nurse Anesthetists Work Unsupervised By Docs"

August 3, 2010 -- The Wall Street Journal reports "the new study confirms that certified registered nurse anesthetists (CRNAs), who receive high-level training, are able to provide the same level of services as anesthesiologists at potentially lower cost." The study authors Brian Dulisse and Jerry Cromwell write "we recommend [the Centers for Medicare & Medicaid Services] return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption..." see the full article or see the abstract of the study in Health Affairs 29, no. 8 (2010): 1469-1475.

 

NPs better at screening, assessment, and counseling and have higher patient satisfaction

June 29, 2010 -- In her article "The Nurse Practitioner Will See You Now," Laura Stokowski at Medscape summarizes the study "The Role Of Nurse Practitioners In Reinventing Primary Care" by Mary Naylor & Ellen Kurtzman in Health Affairs (2010;29:893-899):

They found evidence of the equivalence of care provided by NPs and physicians, beginning with the first randomized trial conducted in 1974. This and numerous subsequent studies confirm that care provided by NPs is as effective as, and no different from, that of physicians in terms of health status, treatment practices, and prescribing behavior. Moreover, NPs achieved consistently better results than their physician colleagues on measures of patient follow-up, consultation time, satisfaction, and the provision of screening, assessment, and counseling.


Patients at nurse-lead atopic eczema clinic had greater improvement of symptoms than those at physician-lead clinic

October 5, 2007 -- A nurse-lead dermatology clinic for children with atopic eczema had a "significantly greater improvement in severity of eczema" than children who attended a physician-lead dermatology clinic. In one measure of treatment adherence, the children's use of wet dressings was 76% in the nurse-lead clinic compared with only 12% for the children in the dermatologist-lead clinic. However, it does not appear as though the study controlled for the length of time spent. Nurses spent 90 minutes in individual and group sessions with patients, and physicians spent 40 minutes with patients, though it is unclear if this was all individual or some group time. See the article...


Cochrane Database reports on benefits of nurse vs. physician care

April 28, 2005 -- In an article entitled "Substituting Nurses For Doctors Results In High Quality Care, Few Savings" researchers report that "[m]any primary care responsibilities can be safely transferred from doctors to appropriately trained nurses...[y]et there is little proof that such a shift reduces physician workload or health-care costs. see the article...


Nurse Midwives credited for second lowest hospital C-section rate in New Jersey, despite serving high-risk community

March 28, 2005 -- Today the Courier News (New Jersey) ran a generally very good piece by Stefanie Matteson about the nurse midwifery program credited with helping the Muhlenberg Regional Medical Center achieve the state's second lowest rate of Caesarian sections, despite serving a low-income urban patient population that is more likely to have high-risk pregnancies. The article highlights the nurse midwives' care model, presents key data and includes good comments from relevant persons, though it could have focused a bit more on the midwives' clinical skill, as opposed to the admirable "cultural climate" they create. more...


Multiple studies find no differences between care delivered by Nurse Anesthetists and Anesthesiologists

2006 -- See the American Association of Nurse Anesthetists' web pages comparing the care of Certified Registered Nurse Anesthetists to that of Anesthesiologists. A number of studies have found no significant differences in patient outcomes based on professional background. See the AANA web pages.


Nurse Midwife care equal in morbidity at a lower cost, with more favorable outcomes and fewer interventions

June 2003 -- The American Journal of Public Health published a study funded by the US Agency for Health Care Research and Quality of low-risk patients receiving collaborative/birth center/midwifery care who had comparable morbidity, preterm birth, and low-birth weight rates to patients receiving physician only care. Collaborative care also resulted in more favorable outcomes and a lower cost to the health care system through spending less time as an in-patient, fewer C-sections, episiotomies, inductions, and vacuum or forceps assisted vaginal births, and more prenatal services delivered despite the lower cost. more...


Nurse-midwives transfer embryos at least as well as gynecologists

May 2003 -- A clinical trial of 102 patients randomly assigned to receive embryo transfers from nurse-midwives or gynecologists found that clinical pregnancy rates were similar--31% for midwives and 29% for gynecologists. The study subjects had a high acceptance rate of midwives on a questionnaire. Bjuresten, K., Hreinsson, J. G., Fridström, M., Rosenlund, B., Ek, I. & Hovatta, O. (2003). Embryo transfer by midwife or gynecologist: a prospective randomized study. Acta Obstetricia et Gynecologica Scandinavica, 82 (5), 462.


London patients rate nurse-led GYN clinics significantly higher than physician-led clinics

April 2003 -- London scientists found that nurse-led GYN clinics had significantly higher patient satisfaction scores than physician-led GYN clinics. Patients rated nurse-led clinics higher in quality, competence, provision of information and overall satisfaction. Miles, K., Penny, N., Power, R. & Mercey, D (2003). Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire. Journal of Advanced Nursing, April, 42 (1), 64.


Meta-analysis: NP patient satisfaction higher and care equal to or better than MD care

April 2002 -- In a meta-analysis of 34 clinical studies published in the British Medical Journal by Horrocks, Anderson & Salisbury comparing care by NP's and physicians, researchers found that patients were more satisfied with their care if it was delivered by a Nurse Practitioner (NP) than by a physician. Compared to physicians, NP's read X-rays equally well, identified more physical abnormalities, communicated better, gave patients more information and taught patients how to provide self-care better. NPs also "undertook more investigations" and spent significantly more time with patients, 14.9 minutes vs. 11.2 minutes for physicians. See the study.


Nurse experts interviewed on nurse practitioner and physician care differences

January 14, 2002 -- Linda Aiken Ph.D., RN and colleagues give a compelling interview to Medscape on differences in care delivery between nurse practitioners and physicians. See the interview.


Physicians: higher patient satisfaction; NP patients: lower blood pressure in study

January 2000 -- M. Mundinger et al. from Columbia University School of Nursing published a randomized clinical research study of 1316 patients in the Journal of the American Medical Association (2000). The study compared care between nurse practitioners and physicians. Patients answered a satisfaction questionnaire after initial appointment and were examined 6 months and 1 year later. At six months, physicians received a significantly higher satisfaction rating (4.2 vs. 4.1 on a 5.0 scale). There were no utilization differences, and the only health status difference was that patients with high blood pressure who were cared for by nurse practitioners had significantly lower diastolic blood pressures. See the abstract.


Advanced Practice Nurses: better compliance, higher satisfaction in meta-analysis

November 1995 -- Brown & Grimes from the Univ. of Texas at Austin School of Nursing published a meta-analysis of 33 randomized studies comparing the outcomes of primary care patients of nurse practitioners (NPs) and nurse midwives (NMs) with those of physicians in the journal Nursing Research. Patients of NPs had significantly greater patient compliance with treatment recommendations compared to physicians. In controlled studies, patients of NPs had greater patient satisfaction and resolution of pathological conditions than patients of physicians. Most other variables were similar. NMs used less technology and analgesia during labor and delivery than did physicians, and the two groups of providers had babies with similar outcomes. Nursing Research 1995 Nov-Dec;44(6):332-9. See the abstract.


NPs--better patient education, care continuity, knowledge about disease, less waiting

October 1995 -- Langner & Hutelmyer published the results of a patient satisfaction survey of 52 HIV-infected primary care patients at an urban medical teaching clinic in the journal Holistic Nursing Practice. Patients of nurse practitioners "fared more favorably" in clinic waiting time, provider knowledge about the disease, continuity of care, and patient education when compared to physician providers. 1995 Oct;10(1):54-60. See the abstract.


Nurses in ENT clinics provide more cost-effective care than physicians

March 2004 -- The article does not appear to have specifically studied patient outcomes beyond cost-effectiveness of care. However, cost-effectiveness can in any case encompass positive health outcomes. See the abstract: Uppal, S., Jose, J., Banks, P., Mackay, E., & Coatesworth, A. P. (2004). Cost-effective analysis of conventional and nurse-led clinics for common otological procedures. Journal of Laryngology & Otology, 118 (3), 189-192.

 

Further studies

Bryant, R; Graham, M.C. Advanced practice Nurses: A Study of Client Satisfaction. Journal of the American Academy of Nurse Practitioners, 14(2) 89-92, Feb 2002.

Mary D. Naylor, Dorothy A. Brooten, Roberta L. Campbell, Greg Maislin, Kathleen M. McCauley, J. Sanford Schwartz. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society, May 2004.

Burl, JB; Bonner, A; Rao, M; Khan, A. Geriatric Nurse Practitioners in Long Term Care: Demonstration of Effectiveness in Managed Care. Journal of The American Geriatrics Society, 46:506-510, 1998

Lin SX, Hooker RS, Lenz ER, Hopkins S. Nurse practitioners and physician assistants in hospital outpatient departments, 1997-1999. Nursing Economics. 2002; 20(4): 174-179.

Grumbach K, Hart LG, Mertz E, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. 2003; 1:97-104.

Stange KC. In this issue: health care inequalities [editorial]. Ann Fam Med. 2003; 1:66-67.

Jackson DL, Lang JM, Swartz WH, et al. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health. 2003; 93:999-1006.

Restrepo, A; Davitt, C.; Thompson, S. House Calls: Is there an APN in the House? Journal of the American Academy of Nurse Practitioners. 13 (12) 560-564, Dec 2001

Lambing, A.Y.; Adams, D.L.C.; Fox, D.H.; Divine, G. Nurse Practitioners' and Physicians' Care Activities and Clinical Outcomes with an Inpatient Geriatric Population. Journal of the American Academy of Nurse Practitioners. 16 (8) 343-352, Aug 2004.

Hoffman, L.A.; Tasota, F.J.; Scharfenberg, C. Zullo, T.G.; Donahoe, M.P. Management of Patients in the Intensive Care Unit: Comparison Via Work Sampling Analysis of an Acute Care Nurse Practitioner and Physicians In Training. American Journal of Critical Care. 12 (5) 436-443. Sept 2003.

Hoffman, L.A.; Tasota, F.J.; Scharfenberg, C. Zullo, T.G.; Donahoe, M.P. Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit. American Journal of Critical Care. 2005;14:121-132.

Russell, D. ; VordeBruegge, M.; Burns, S.M. Effects of an Outcomes-Managed Approach to Care of Neuroscience Patients by Acute Care Nurse Practitioners. American Journal of Critical Care. 11 (4) 353-362. July 2002.

Kleinpell, R.M. Acute Care Nurse Practitioner Practice: Results of a 5-Year Longitudinal Study. American Journal of Critical Care. 14 (3) 211-221. May 2005.

Adams KF, Baughman KL, Dec WG, et al (1999). HFSA (Heart Failure Society of America) guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction-pharmacological approaches. Journal of Cardiac Failure, 5(4), 357-382.

Albert, N & Young, J. (2001) Heart failure disease management: a team approach. Cleveland clinic journal of medicine, 68(1), 53-64.

Bargardi AM. Impact of nurse practitioner-implemented evidence-based clinical pathways on "best practice" in an interventional cardiology program. 72nd Scientific Sessions of the American Heart Association. www.medscape.com/medscape/CNO/1999/AHA/day2/08-bargardi.html

Brass-Mynderse NJ. (1996). Disease management for chronic congestive heart failure. Journal of Cardiovascular Nursing, 11(1), 54-62.

Dahl J & Penque S. The effects of an advanced practice nurse-directed heart failure program. The Nurse Practitioner, 25(3), 61-77.

Evangelista, L & Dracup, K ( summer 2000) A closer look at compliance research in heart failure patients in the last decade. Progress in cardiovascular nursing, 97-103.

Fonarow, G, Stevenson L, Walden N, et al. (1997). Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol, 30(3), 725-732.

Hershberger, R E, Hanyu, Ni, Nauman, D. J, et al. (2001) Prospective Evaluation of an outpatient heart failure management program. Journal of Cardiac Failure, 7(1), 64-74.

Martens KH & Melor SD. (1997). A study of the relationship between home care services and hospital readmission of patients with CHF. Home Healthcare Nurse, 15(2), 123-129.

Paul, S. (1997). Implementing an outpatient CHF clinic: The nurse practitioner role. Heart and Lung, 26(6), 486-491.

Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE & Carney ME. (1995). A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. The New England Journal of Medicine, 333(18), 1190-1195.

Ramahi, T, Longo, M, Rohlfs, K, Sheynberg, N. (2000). Effect of heart failure program on cardiovascular drug utilization and dosage in patients with chronic heart failure. Clinical cardiology, 23, 909-914.

 

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