By Dorothy Brooks
Professional nursing organizations are pushing back against a working paper from the National Bureau of Economic Research (NBER).
In that paper, the authors suggested care delivered in the ED by nurse practitioners (NPs) who are not operating under the supervision of physicians actually results in more resource use and higher costs than care provided by emergency physicians (EPs) working in the same setting.1 The three-year study concerned NPs at a single ED within the Veterans Health Administration (VHA) where NPs were practicing independently at the time. The authors reported NP care was associated with a 20% increase in 30-day preventable hospitalization rates vs. care delivered by their physician colleagues.
Also, the authors reported patients who received care from NPs recorded longer lengths of stay (LOS) on average (by 11%). Their total cost of care was higher (by 7%) than care delivered by EPs. This was the case even when considering the fact physicians are paid roughly twice as much as NPs, according to the authors.
However, nursing organizations took issue with the findings, noting the tiny sample size and the fact the paper has not been peer reviewed. “In this working report, the authors’ conclusions are not based on accurate or generalizable data, nor are they supported by the unadjusted data within the same report,” states Wesley Davis, DNP, APRN, CEN, FAANP, FAEN, president of the American Academy of Emergency Nurse Practitioners (AAENP).
Davis also says the NBER stated that working papers are shared only for discussion and that no conclusions should be drawn. “Yet using a small sample from a single work setting, coupled with inaccurate definitions of full practice authority within a non-peer-reviewed paper, faulty conclusions are offered in this report,” Davis notes.
April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners (AANP), shares similar concerns, stressing the working paper is not an accurate representation of NP duties or value. “For decades, nurse practitioners have been providing high-quality care to patients across the lifespan in nearly every healthcare setting,” she says. “NP care is safe and cost-effective, with studies finding significant savings for patients with complex and chronic conditions.”
To bolster these points, the AANP pointed to two studies, the authors of which concluded care delivered by NPs in the ED is cost-effective. In 2017, researchers shared data from an ED in Southern California that showed using NPs as providers in triage (PIT) was not associated with excessive test-ordering or prolonged ED patient stays vs. physicians serving in the PIT role.2
In a recently published paper, researchers reported that adding a 24/7 trauma NP service model to the ED shortened LOS and resulted in fewer consultations.3
Still, neither the NBER paper nor the studies AANP referenced concerned the specific difference between NPs practicing independently in the ED vs. NPs who are providing care under the supervision of EPs. However, in a December 2022 online article about the NBER paper, the American Medical Association (AMA) stressed the importance of placing physicians at the head of the care team.4
“This study leverages data from a time — 2007 to 2020, right before the pandemic — in which NPs within the VHA were truly practicing without physician supervision,” the AMA noted. “The study found the physician-NP gap on cost and quality grew with patient complexity, with NPs being more likely to admit to the hospital patients with complex or severe conditions. The effect of NPs on lengths of stay and medical costs also rose with the complexity of the patient’s condition.”
The AMA further observed that while physicians complete between 10,000 and 16,000 hours of clinical education and training, NPs complete between 500 and 720 hours of clinical training. “Patients deserve care led by physicians — the most highly educated, trained, and skilled health professionals,” the AMA wrote. “That is why the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety as part of the AMA Recovery Plan for America’s Physicians.”5
Despite such views, it is a priority of the AANP to empower more NPs with full practice authority, a determination generally made at the state level of government.6 Furthermore, the organization stresses the findings of one small study that included just 156 NPs cannot be generalized to all the NPs who work in EDs.
“As the healthcare industry faces unprecedented workforce shortages and increasing healthcare needs, NPs are and will continue to be vitally important to patient access to high-quality healthcare,” Kapu says. “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.”
“One erroneous report does not jeopardize decades of care delivery,” Davis says. “It does, however, serve to encourage organizations and providers to provide solid, evidence-based, generalizable outcome research. That is a priority mission of AAENP in 2023 — to partner with our [emergency medicine] workforce team members to demonstrate the continued value of NP care within emergency settings.”
In a statement released on Dec. 14, 2022, Jennifer Schmitz, MSN, EMT-P, CEN, CPEN, CNML, FNP-C, NE-BC, then-president of the Emergency Nurses Association (ENA), voiced strong support for APRNs working in the ED.7
“ENA has concerns about the study’s methodology and the resulting implication that minimizes the important role that APRNs play in patient care and the benefits they bring to the ED,” she said. “Amid a nurse staffing crisis and the significant pressures being put on emergency departments during the so-called ‘tridemic,’ today’s focus should be on strengthening the interprofessional approach to healthcare that ensures the best care for all patients in the ED.”
REFERENCES
1. Chan DC, Chen Y. The productivity of professions: Evidence from the emergency department. National Bureau of Economic Research. October 2022.
2. Begaz T, Elashoff D, Grogan TR, et al. Differences in test ordering between nurse practitioners and attending emergency physicians when acting as provider in triage. Am J Emerg Med 2017;35:1426-1429.
3. Hardway J, Lucente FC, Crawford AT, et al. Impact of the 24/7 nurse practitioner model on emergency department stay at a level 1 trauma center: A retrospective study. J Clin Nurs 2023;32:517-522.
4. O’Reilly KB. 3-year study of NPs in the ED: Worse outcomes, higher costs. American Medical Association. Dec. 7, 2022.
5. American Medical Association. AMA Recovery Plan for America’s Physicians.
6. American of Association of Nurse Practitioners. Issues at a glance. Full practice authority. Revised October 2022.
7. Emergency Nurses Association. ENA statement on nurse practitioners in the ED. Dec. 14, 2022.
Professional nurse groups are pushing back against a working paper in which the authors suggested care delivered in the ED by nurse practitioners who are not operating under the supervision of physicians actually results in more resource use and higher costs than care provided by emergency physicians working in the same setting.
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