Working Paper Claims Nurse Practitioners Have Lower Productivity Than Physicians
Updated 1/11/2023
The American Association of Nurse Practitioners provided additional information regarding this white paper.
Statement From The American Association of Nurse Practitioners
The American Association of Nurse Practitioners President, April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN provided the following statement to Nurse.org regarding this working paper.
“For decades nurse practitioners (NP) have been providing high-quality care to patients across the lifespan in nearly every healthcare setting,” said April Kapu, President of the American Association of Nurse Practitioners. “NP care is safe and cost-effective with studies finding significant savings for patients with complex and chronic
“The recently released working paper is based on a very small sample size, in a single work setting, and is not an accurate representation of NP practice or value. People are choosing to see NPs for their care, and this is evidenced by over 1 billion visits each year. Meeting the nation’s healthcare needs requires all of us. The American Association of Nurse Practitioners® stands with patients and is committed to providing solutions to today’s healthcare challenges.”
AANP Provides Background On The Working Paper
There is a lot of pushback on this working paper. In fact, even the paper itself comes with a warning, “NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of Directors that accompanies official NBER publications.” If you read the full working paper and look at Table 1 with the UNADJUSTED data, it tells the real story. 1. More cost savings with NPs. 2. Less likely to have 30-day preventable hospitalization if seen by an NP. 3. Half as likely to experience 30-day post-visit mortality if seen by an NP.
There are 50 years of research that supports the fact that nurse practitioners provide exceptional care. A research study by Begaz et al 2017 examined data from a Los Angeles County Emergency Department, and demonstrated that utilizing NPs as providers in triage (PIT) “does not appear to be associated with excess test ordering or prolonged ED patient stays [compared to physicians].”
Using eight years of data from the National Hospital Ambulatory Medical Care Survey, Mafi et al 2022 found the NP/PA-only group used fewer medications, diagnostic tests, procedures, hospitalizations, and low-value CT/MRI studies than physicians.
In yet another study, Hardway et al (2022) found adding a 24/7 trauma NP service model to the emergency department patient flow significantly lowered ED length of stay, had a faster time to discharge, and involved one less consultation.
It is important to rely on the vast amount of data and research that is available to draw conclusions, not a single working paper that has not been peer-reviewed by other health professionals or institutions. It is impossible to generalize this new working paper’s findings to NPs in all emergency departments and across all settings. This study included 156 NPs when there are 355,000 licensed NPs in the nation. The sample size is too small to generalize to NPs in all emergency departments.
Original article published 1/9/2023
Expanding the scope of practice for nurse practitioners (NPs) is a hot topic in many parts of the country. Those in favor of increasing nurse practitioner autonomy say that doing so will reduce gaps in access to care, ease the worsening physician shortage, and increase patient satisfaction. Yet, the American Medical Association (AMA) argues that expansion could threaten patient safety and raise healthcare costs. A new study agrees with the latter.
A 93-page working paper, authored by economists David C. Chan, Jr. and Yiqun Chen, reviews findings from a sample of 1.1 million emergency department (ED) visits. The study was designed to evaluate utilization and health outcomes for encounters performed by NPs versus physicians. The paper calls the comparisons "stark."
Here's a look at what they found.
The Experiment Design
The paper, titled The Productivity of Professions: Evidence from the Emergency Department, is based on a study of Veterans Health Administration (VA) administrative health records. Researchers suggest that this sample was ideal because it provides a large number of records with varied demographics and medical problems. Using the VA records allowed investigators to compare nurse practitioner (NP) and medical doctor (MD) performance in similar settings and circumstances. Read the full study here.
The VA health system is the nation's largest healthcare delivery system, employing over 371,000 healthcare professionals and providing care to more than 9 million veterans. On December 14, 2016, The Department of Veterans Affairs (VA) granted full practice authority to four advanced practice roles, including NPs. This rule allows NPs to practice autonomously without physician supervision.
Researchers gathered information from ED visits between January 2017 and January 2020. They excluded cases arriving between 6 pm and 7 am because there were fewer NPs on night shifts. In total, they looked at 1.1 million cases from 44 different ED sites. The provider mix included 156 NPs and 1,348 physicians.
The Findings
The investigators looked at two primary indicators of productivity: resource use and patient outcomes (e.g., length of stay, 30-day preventable hospitalization). In the end, they found that patients seen by NPs used more medical resources and incurred higher costs than those seen by doctors in the ED setting. Additionally, study results suggested that NPs have less favorable patient outcomes measured by preventable hospitalizations.
Here's a summary of the working paper findings:
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Nurse Practitioners increase length of stay by 11 percent
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Nurse Practitioners raise the cost of ED care by 7 percent
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Nurse Practitioners raise 30-day preventable hospitalizations by 20 percent
Those figures translate to an 18-minute longer length of stay and a $66 increase in cost per ED visit.
Source: The Productivity of Professions: Evidence from the Emergency Department
In short, the paper states: "we find that, compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes."
Differences Between NP and MD Cases
Next, researchers looked at reasons and mechanisms for lower productivity among NPs. They suggest that experience, information-gathering, decision-making, and case complexity were the main factors.
Experience matters
Researchers found that utilization was lower among NPs who had seen more patients (both in general and for the current diagnosis). Provider experience did not, however, reduce the gap in preventable hospitalizations.
"Lower diagnostic skills"
The study found that NPs were more likely to "gather external information." The paper's authors suggested that NPs were compensating for their ability to perceive less information on their own than doctors. Data showed that NPs were more likely to order X-rays and CT scans than physicians and more likely to use consults.
Researchers pointed out that collecting "resource-intensive information from external sources" increases the length of stay and medical costs since they take time and resources to complete.
Prescription patterns
In the sample, NPs also exhibited prescription patterns different from physicians. The paper suggests that these findings are also consistent with lower skills.
Relative to doctors, NPs were less likely to prescribe opioids and more likely to prescribe antibiotics.
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Nurse Practitioners were lower in opioid prescriptions by 1.8%. That could have led to preventable hospitalization among patients who should have received them, meanwhile avoiding addiction and overdose in those who should not.
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Nurse Practitioners increased antibiotic prescriptions by 4.0%. Antibiotics have higher false-negative costs–e.g., not treating a potentially life-threatening infection compared to antibiotic resistance.
The study concedes that opioids have higher health risks if prescribed incorrectly, while antibiotics have higher health risks if not prescribed.
Other Findings
Notably, despite productivity differences between NPs and MDs, investigators found even larger productivity differences within professions. Some NPs had significantly higher productivity than others.
Yet overall, the paper concludes that using NPs in this setting did not benefit the organization financially. It reasons that "the costs implied by lower productivity outweigh any salary savings from hiring NPs" even though NP wages are half as much as a physician's salary.
It goes on to say that training and experience, different skill levels, and differences in patient populations may explain the productivity gap between the two professions. NP education is also typically half as long as a physician's training.
The Takeaway
According to the latest projections by the Bureau of Labor Statistics, demand for nurse practitioners has surged and will continue over the next decade. The growth is mainly due to workforce needs and patient trends in demographics and chronic diseases.
Even though the need for advanced practice nurses is growing, some argue that NP's skills differ from fully trained physicians.
Still, a recent poll conducted on behalf of CVS Health found that "82% of patients support allowing nurse practitioners to practice to the full extent of their education." The same report showed that nearly 80% of healthcare providers, including doctors, physician assistants, and therapists, agree and support it.
As state and federal agencies examine the implications of expanding full practice authority to advanced practice nurses, more research is needed to optimize the healthcare system using these highly skilled and qualified practitioners.
