A newly proposed rule by the US Department of Veterans Affairs (VA) has generated much controversy. This rule would permit full practice authority to all advanced practice registered nurses (APRNs), including certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified nurse midwives (CNMs) in the VA health system, allowing them to practice to the "full extent of their education, training, and certification, without the clinical supervision of physicians, regardless of individual state restrictions..."
Many of the issues brought up by those against this proposal concern the safety and quality of APRN care. To shed some light, we took a close look at the scientific evidence with Julie Stanik-Hutt, PhD, ACNP/GNP-BC, CCNS, author of the 2013 systematic review, The Quality and Effectiveness of Care Provided by Nurse Practitioner.
Medscape: Your original review about the quality and effectiveness of NP care looked at studies published from 1990 to 2009. In light of all of the interest in the current VA proposal to allow APRNs in the VA system to practice at the top of their license, it seems time to revisit the evidence for NP care. Could you tell us a bit about your 2013 analysis and the major findings?
Dr Stanik-Hutt: In 2010 we systematically sought and evaluated all of the research that examined outcomes that related to care safety (prevention of injury or loss), quality (level of excellence), and effectiveness (compliance with guidelines and/or production of desired result) in US patients cared for by an NP, CNS, or CNM as compared to patients cared for by a physician.[1,2,3]
Two reviewers used study inclusion/exclusion criteria to independently review each title, abstract, and study for relevance to the project. This honed the original 27,993 titles to 1673 reports (published and unpublished) and finally yielded 96 studies that were included in the final review (49 on NPs, 24 on CNSs, and 23 on CNMs). We were able to aggregate results from 71 studies (37 on NPs, 13 on CNSs, and 21 on CNMs). We rated the quality of the studies using a modified Jadad score and then the strength of the evidence using GRADE Working Group Criteria. Our conclusions were based on the results from these processes.
Here is what we found:
For patients cared for by CNSs: There was a high level of evidence that CNS involvement reduced hospital length of stay and reduced costs but did not affect patient satisfaction with care. There was a moderate level of evidence that involvement of a CNS reduced complications. There was a low level of evidence that involvement of the CNS affected the patient's quality of life.
For patients cared for by NPs: There was a high level of evidence that blood glucose levels, blood pressure levels, satisfaction with care, perceived health status, functional status, numbers of unexpected ED or office visits, numbers of hospitalizations, and mortality rates in patients cared for by NPs were similar to those of patients cared for by physicians. In addition, patients cared for by NPs had lipid levels that were better than those of patients cared for by physicians. There was a moderate level of evidence that patients of NPs had lengths of stay that were similar to those of patients cared for by physicians. We found a low level of evidence that critically ill patients cared for by NPs or by physicians had a similar duration of ventilation. We also found a moderate level of evidence that transitional care provided by a CNS or an NP reduced patient readmissions.
For patients cared for by CNMs: There was a high level of evidence that CNM-managed patients, in comparison to those managed by physicians, had lower rates of episiotomy, perineal lacerations, operative vaginal birth and cesarean birth, as well as similar APGAR scores and numbers of low-birthweight infants. There was a moderate level of evidence that CNM-managed patients had higher rates of breastfeeding. In addition, rates of vaginal birth after cesarean section and need for NICU admission were similar in CNM- and physician-managed patients.
We concluded that care by NPs, CNSs, and CNMs produced patient outcomes that were similar to those related to care provided by physicians, and in some instances were better than those from care provided by physicians (lipid levels, use of episiotomy, and rates of perineal lacerations, operative vaginal birth rates, rates of cesarean births, length of stay, and costs). The take-home message was that care by NPs, CNSs, and CNMs was safe, high-quality, and effective.
We initially had intended to evaluate data on CRNA outcomes in the systematic review but were not able to find enough studies and outcomes that met review requirements for inclusion. The limited literature, which examined CRNA and physician anesthesia care at the time of our review, reported no differences in patient outcomes between these two provider types.[4,5,6,7,8,9] It is important to note that for more than 30 years, the morbidity and mortality associated with anesthesia care has been exceedingly low, prompting investigators to focus their attention on other topics, so it is not surprising that we were not able to find studies comparing the two provider types.
Medscape: A lot of research has been reported since your systematic review. Please tell us about any more recent studies that look at quality and effectiveness of care by APRNs. Do the newer studies support your earlier findings?
Dr Stanik-Hutt: Data continue to accumulate that support the positive patient outcomes derived from APRN care. The most important research reported since our work was completed focuses on the quality and safety of care provided by CRNAs.
In 2010, two health economists used Medicare and Medicaid data to examine complication and mortality rates in patients cared for by CRNAs in solo practice versus those of physicians. In other words, they asked whether physician involvement in CRNA anesthesia care made any meaningful impact on patient outcomes. Investigators controlled for patient age, gender, race, case complexity, and diagnosis. They found that that care by CRNAs and physicians produced similar complication and mortality rates, and concluded that autonomous CRNA care (without physician oversight) was safe and did not expose patients to any increased harm.
Another group of investigators used economic modeling to evaluate the cost-effectiveness of several anesthesia care models (autonomous CRNA care, physician-supervised CRNA care, physician-directed CRNA care, autonomous physician care). They began by examining the evidence regarding the quality of care provided by each care model and concluded that there was no difference in the patient outcomes among the different models. In fact, they concluded that physician anesthesia providers and CRNAs "provide the same services and are interchangeable."
They then used two sophisticated statistical methods, including the use of claims data, to compare costs of anesthesia care. The models found that autonomous CRNA care was consistently the most cost-effective care model, that physician-directed CRNA care creates delays in surgical patient care, and that physician-supervised and physician-directed CRNA care increased hospital costs. They specifically noted that physician-supervised and physician-directed CRNA care had more to do with staffing and costs than with clinical decision-making. The authors also compared the typical educational costs for physician anesthesia providers and CRNAs. They concluded that in order to maintain quality while controlling costs, CRNAs need to be allowed to practice autonomously.
With the move to value-based reimbursement, APRNs will need to continue to demonstrate the effectiveness of their care by documenting that the patient outcomes match or exceed quality benchmarks.
Medscape: The issues you addressed in your 2013 analysis are certainly key to the current discussion: healthcare access, cost, and quality of APRN care. Many physician groups have publically expressed their concerns that APRN care for US veterans without physician supervision will be unsafe, substandard, or otherwise lacking. Is there any evidence that supports this concern?
Dr Stanik-Hutt: CRNAs have provided anesthesia care for 150 years. CNMs have provided primary and perinatal care to women and infants since the 1920s, and NPs have been practicing for 50 years. If evidence existed to support organized medicine's disparaging claims regarding APRN care, it surely would have surfaced before now. In fact, there is no study that has demonstrated that patients are exposed to higher risk based on their decision to receive care from an APRN. Over the past 35 years, no fewer than nine other systematic reviews, meta-analyses, and governmental studies have examined the safety, quality, and effectiveness of care provided by APRNs.[12,13,14,15,16,17,18,19,20] They have consistently found that APRN care quality is excellent and on par with that of physicians. Our systematic review echoed those findings.
In fact, many physicians support the VA proposal. They have worked with APRNs, know the skills that APRNs bring to the table, and appreciate the added value that APRNs contribute. They know that when APRNs encounter situations that exceed their capabilities, they inform the patient and then obtain assistance from other appropriate clinicians who can provide the services the patient needs.
These physicians recognize that APRNs, like all other healthcare providers, collaborate with other clinicians on a daily basis to assure that patient needs are met. They also recognize that it takes a variety of healthcare professionals from different disciplines to meet the complex needs of patients requiring chronic and complex care.
That said, some physicians have not had the privilege of working with APRNs. Their professional education may have occurred in a "medical silo" where the opportunities for interprofessional education were few or nonexistent. They may not know the evidence regarding APRN care processes and outcomes. Consequently, they are not aware of the education and qualifications that APRNs possess.
Medscape: What is your perspective on the current VA proposal? What do you believe is the impetus for the proposal? It seems that assuring that all APRN licenses are the same (eg, independent) versus the patchwork of state licenses that exists now would make VA care more efficient. Why do you think there is such vehement concern by MD groups? How different is the VA proposal from the way APRNs already practice in many states?
Dr Stanik-Hutt: The current VA proposal would allow all APRNs to practice to the full extent of their education. This policy is already followed by other federal health systems, such as the Indian Health Service. In addition, APRNs at many VA healthcare facilities have already been approved for this so-called full practice authority. So the VA proposal would maximize the practice privileges of APRNs within the limits of their education and also standardize APRN credentialing across all VA healthcare facilities.
This proposal comes at a time when many stakeholders have come forward to support full utilization of the knowledge and skills of APRNs. The Institute of Medicine, AARP, National Governors Association, and National Conference of State Legislatures have all recommended that NPs specifically and APRNs in general should be allowed to work to their full capabilities. The Federal Trade Commission has studied the evidence and also weighed in to support legislation and regulations that remove unneeded barriers that prevent APRNs from providing critically needed healthcare services. Over the past 5 years, several states have passed laws that remove these barriers and authorize APRNs, especially NPs and CNMs, to practice to the full extent of their education (so-called full practice authority). The VA proposal follows these trends.
It also comes at a time when care safety, quality, effectiveness, and costs are under intense scrutiny. Economic pressures require that all healthcare providers are used effectively to address the health needs of our citizens at an affordable cost. The VA specifically is struggling to meet the healthcare needs of a growing population of veterans. It has made great efforts to hire physicians, but we all know that physicians alone cannot fill existing care gaps, especially in primary care.
When you know that the care provided by APRNs produces outcomes that are comparable to those produced by physicians, it is just logical that you would maximize the use of both APRNs and physicians to provide care within their respective scopes of practice.
Medscape: I understand that you are a veteran yourself. Do you believe that the proposal to allow APRNs to practice independently is a reasonable approach to begin to improve care for veterans?
Dr Stanik-Hutt: I am proud to have served as a Nurse Corps officer in the Navy. I am married to a retired naval officer and we count 10 other veterans in our immediate family. My husband and two cousins currently receive care at VA healthcare facilities. We've all received care from NPs, CRNAs, and/or CNMs during and after military service. The care we received was excellent. So when the provider turns out to be an APRN, we see it as a standard operating procedure.
As a Navy nurse and later as a civilian, I had the opportunity to observe how those APRNs practiced. And in reality, each one practiced autonomously in making clinical decisions. As a nurse and a veteran, it has been gratifying to learn that a number of veteran associations are supporting the proposed rule change, including the Air Force Sergeants Association, the Military Officers Association of America, and several posts of the American Legion.
I believe that standardizing VA policy to provide all VA APRNs full practice authority, and to standardize APRN credentialing and privileging, would increase veterans' access to care, streamline VA healthcare system operations, and improve the care provided to veterans. The VA assigns every veteran to a primary care Patient Aligned Care Team (PACT), a type of patient-centered care. PACTs may only be led by a physician, but they include an NP as an "associate provider." Some PACTs use the NP as a care manager, a role that can also be filled by an RN.
Both of these PACT arrangements (exclusively physician-led PACTs and NPs as PACT care managers) underutilize the skills of an NP. Specifically, assigning both a physician and an NP to the PACT is duplicative, as both are qualified to provide primary care services. At the same time, the VA has a shortage of primary care PACT physician leaders. If the VA proposal is adopted, NPs could lead PACT teams, eliminating unnecessary duplicative services and thereby increasing the number of teams available to serve veterans. It would be a force multiplier and would increase veterans' access to care.
In the VA, CRNAs practice in a model of physician supervision. As noted by economic models, autonomous CRNA practice prevents surgical care delays and is the most cost-effective model of anesthesia care. If the VA proposal is adopted, CRNA practice would become autonomous and reduce the costs associated with the current physician supervision model. The monies associated with the potential cost savings could be redirected to other needed veteran care services.
In summary, adopting the proposed VA rule would produce a win-win-win—for veterans, for APRNs, and for the VA.
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Medscape Nurses © 2016 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: APRNs vs Physicians: Outcomes, Quality, and Effectiveness of Care According to the Evidence - Medscape - Jul 12, 2016.