Clinical Reviews
With comments by Lynn Keegan, RN, PhD, HNC, FAAN
Care Outcomes in Patients Treated by Nurse Practitioners
Source: Mundinger MO, et al. Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA 2000;283:59-68.
Objective: To compare outcomes for patients randomly assigned to nurse practitioners (NPs) or physicians (MDs) for primary care follow-up and ongoing care after an emergency department or urgent care visit.
Design: Randomized trial conducted from August 1995 to October 1997, with patient interviews at six months after initial appointment and health services utilization data recorded at six months and one year after initial appointment.
Setting: Four community-based primary care clinics (17 MDs) and one primary care clinic (seven NPs) at an urban academic medical center.
Patients: Of 3,397 adults originally screened, 1,316 patients (mean age 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either an NP (n = 806) or MD (n = 510).
Main Outcome Measures: Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results six months later; and service utilization (obtained from computer records) for one year after initial appointment, compared by type of provider.
Results: No significant differences were found in patients’ health status (NPs vs. MDs) at six months (P = 0.92). Physiological test results for patients with diabetes (P = 0.82) and asthma (P = 0.77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for NP patients (82 vs. 85 mm Hg; P = 0.04). No significant differences were found in health services utilization at six months or one year. There were no differences in satisfaction ratings following the initial appointment (P = 0.88 for overall satisfaction). Satisfaction ratings at six months differed for one of four dimensions measured (provider attributes), with MDs rated higher (4.2 vs. 4.1 on a scale where 5 = excellent; P = 0.05).
Conclusion: In ambulatory care situations in which patients were randomly assigned to NPs or MDs, and where NPs had the same authority, responsibilities, productivity, administrative requirements, and patient population as MDs, patient outcomes were comparable.
Comments: Previous studies have suggested that the quality of primary care delivered by NPs is equal to that of MDs. However, those studies did not measure NP practices with the same degree of independence as the comparison MD practices, nor did they directly compare outcomes between providers.
The general public and professional caregivers need to be aware that NPs can give equal care. Nurses have fought hard for reimbursement and this study demonstrates that their battles have been justified. NPs are now eligible for reimbursement from Medicaid in every state, and Medicare Part B and commercial insurance reimbursement for primary care services. As NPs seek to define their niche, they can refer to this study to bolster their own self-confidence as well as those with whom they work and serve.
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