Advocates for Evidence-Based Health Policy Speakers
Like Cats and Dogs
Recent research does little to resolve the disagreement surrounding the scope to which nurse practitioners (NPs) may ply their trade without physician oversight. In full scope of practice states, NPs may perform relatively unrestricted primary care including ordering of diagnostic imaging, laboratory tests, and prescription medications. In reduced and restricted scope of practice states, one or more of these activities is limited and requires physician supervision. What we seem to know is that states with highly restrictive scope of practice regulations block the productivity of NPs and may decrease access to primary care. Currently 12 states have restricted NP practice.
Researchers tested two hypotheses. First, is the quality of primary care provided to Medicare beneficiaries by NPs better in states that reduce or restrict NP practice compared to states that have no restrictions? Second, do scope of practice restrictions negatively affect the quality of primary care by limiting access.
If the quality of care is higher in restricted practice states, it would suggest that more stringent physician oversight of quality of care is protective. Independent variables accessing access to care included aspects of chronic disease management, cancer screening, ambulatory care-sensitive hospital admissions, all cause 30-day readmissions, and preventable emergency department visits. The authors controlled for the usual demographic variables, dual Medicaid/Medicare status, location, and treatment setting.
In a sample of almost 300,000 beneficiaries, there was no discernible pattern to the authors’ findings, forcing them to conclude that there is not a consistent association between quality primary care provided by NPs and state scope of practice laws. There may be other salient factors overriding the effect of state regulations. For instance, beneficiaries receiving care from NPs in full scope of practice states were 37% more likely to receive breast cancer screening. Is this simply because NPs can order the screening unhampered or might there have been social marketing campaigns encouraging breast cancer screening in the states?
The policy prescription is unclear, but practitioners of all types manage to provide exceptional care despite barriers at the organizational and societal level. While granting NPs full scope of practice is not associated with better primary care, it certainly isn’t making primary care worse, and removing restrictions may make this difficult job that much easier to deliver to patients.
Abstract
CONTEXT: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited.
METHOD: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care.
FINDINGS: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions.
CONCLUSION: State regulations restricting NP SoP do not improve the quality of care.
PMID: 28906171
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