Chapter Four ('Nurse Practitioners')

Physician Assistants and Nurse Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. Specialization of advanced NP's:
   
   
   adult nurse practitioner
   family nurse practitioner
   pediatric nurse practitioner
   gerontological nurse practitioner
   school nurse practitioner
   women's health nurse practitioner
   
   
2. Note of a recent trend to "use acute care and neonatal intensive care nurse practitioners for hospital residency substitution." (p42)
   
   
3. 'Most NP, CNM programs completed in two year, post- baccalauriate programs.' (p42) This compares to 7-8 years for physicians.
   
   
4. 'A 1986 Office of Technology Assessment study of documents states that patient outcomes are equivalent or superior to those effected by physicians.' (p43) Need to identify what outcomes were measured in which areas of care and what percentage of total health care this is.
   
   
5. 'Cost per labaratory test was $20.49 vs $22.36 (8 percent savings) for NP vs MD patients.' (p43) This is not very much, and were the tests ordered by physicians inappropriate or appropriate? Were the patient mixes the same? Does this include administrative costs to have NPP's?
   
   
6. 'Nurses (practitioners?) spent 24.9 vs 16.5 minutes for MD's with each patient.' (p43) Is the time spent with the patient by regular nursing staff evaluated for these groups?
   
   
7. 'The cost estimates noted are confounded by regional and salary differentials' (p43)
   
   
8. 'Analysis of differences between patient groups in these studies (as to severity of problem or other) was not possible because of small sample size.' (p44)
   
   
9. Certified Nurse Midwife patients had equivalent rates of Cesarian Sections in these studies. 'The average rates of prematurity were 4.5% for CNM and 10% for MD patients.' "The CNM/MD comparison studies did not control for patient risk." (p44)
   
   
10. "Although the expanded roles for NPs and CNMs were originally designed for rural areas and underserved populations, most of the research was conducted in urban areas." (p44)
    
    
11. "Much more research is needed regarding the care provided by NP's and MD's." (p45)`
    
    
12. "The health care system must find a way to provide reimbursement for time spent in history taking and patient counseling." (p48) Note: if physicians were adequately reimbursed for this, then perhaps they would do more. (reimbursement versus training).
    
    
13. Note that the nurse specialist author of this chapter advocates more nurse practitioners.