There is a growing movement in the United States that seems aimed at expanding the scope of independent practice for nurse practitioners(www.nytimes.com) so they can substitute for primary care physicians. However, there is little evidence that nurses can replace primary care physicians effectively.
In a 2004 article, researchers with the Cochrane Database of Systematic Reviews suggested that, "appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients." However, the authors went on to acknowledge that the available research on the topic was very limited. A 2009 update(onlinelibrary.wiley.com) did not include any more recent studies.
The articles included in the 2004 and 2009 Cochrane reviews raise some significant concerns. For example,
- 14 of the articles included in the most recent version of the review were more than 30 years old;
- some of the studies were focused on the management of a specific disease;
- others used one nurse in a single practice;
- many of the studies were conducted outside the United States; and
- several studies appear to include some degree of physician collaboration.
These concerns severely limit the ability to generalize findings to a larger population. It also is troubling that many of these studies were not randomized trials, which can lead to a selection bias among patient panels.
As nurse practitioners push to expand their scope of practice, AAFP members have looked on with concern about what this could mean for patients. Thus, delegates to the AAFP's 2010 Congress of Delegates adopted a resolution calling for a new study of nurse practitioners and their scope of practice compared with that of family physicians.
Several members of the University of Missouri Department of Family and Community Medicine recently undertook a reanalysis and update of data on the nurse practitioner issue from the Cochrane reviews. We found that the evidence continues to be insufficient to make conclusions about comparability of care.
As part of our analysis, we used search parameters similar to those that identified the original 25 articles in the Cochrane reviews. We were able to include 16 more recent studies, but we found the same concerns existed for this updated collection that existed for the original reviews.
More rigorous study of the comparability between family physicians and nurse practitioners is needed, and it may take a large effort backed by the Agency for Healthcare Research and Quality or the NIH to undertake the level of research needed to glean meaningful results.
In the meantime, the AAFP maintains that nurse practitioners should not work as independent health care providers. Instead, they should be part of an integrated practice arrangement under the direction of a physician. Indeed, a comparison between the training of family physicians and that of nurse practitioners shows the differences that would likely affect breadth and depth of patient care. Nurse practitioners receive two to three years of postgraduate training and fewer than 6,000 hours of clinical training, while physicians must complete medical school, residency and more than 20,000 hours of clinical training.
The ongoing health care reform efforts in the United States likely will result in improved primary care access for many Americans, and multidisciplinary care approaches will be necessary to accommodate such access. However, substituting independent nurses for physicians providing comprehensive primary care is not sufficiently supported by current research.
Erik Lindbloom, M.D., M.S.P.H., is associate professor in the department of family and community medicine at the University of Missouri, or MU, School of Medicine in Columbia; director of the school's family medicine fellowship program; and associate director of the MU family medicine residency program. His co-investigators on this project are Sonia Acevedo-Espinoza, M.D.; Susan Meadows, M.L.S.; Laura Morris, M.D.; and Amanda Swenson, M.D., all also from the school's department of family and community medicine.
Editor's Note: The authors will be submitting the full findings of their review to a peer-reviewed publication in the coming months.