NPs Increasingly Fill Primary Care Gaps

Nicola M. Parry DVM

June 06, 2018

Primary care practices increasingly employ nurse practitioners (NPs) to help close the gap in care delivery, especially in rural areas, a recent study published in the June issue of Health Affairs suggests.

"In both rural and nonrural settings, a higher percentage of practices in states with full scopes of practice included NPs, compared to those in states with practice restrictions — a finding that is aligned with the results of prior studies," write Hilary Barnes, PhD, APRN, from the University of Delaware, Newark, and colleagues.

The growing shortage of physicians entering primary care is particularly problematic in rural areas where physician numbers are already sparse, the authors say.

This opens up potential for NPs to fill this primary care gap. NPs can provide most of the services that physicians in primary care offer. Indeed, prior studies have shown that NPs have been shown to deliver safe and high-quality primary care that correlates with a high level of patient satisfaction.

However, data are lacking to indicate how NPs have been integrated into primary care practices in recent years and whether scope-of-practice laws and expansion of eligibility for Medicaid might affect use of NPs in this way.

Therefore, Barnes and colleagues analyzed a national commercial physician practice database for the period from 2008 through 2016 to investigate the use of NPs in primary care practices in both rural and nonrural areas.

They categorized states as "having restricted scopes of practice if an NP was required to maintain collaborative agreements [with a physician] for practicing and prescribing, reduced scopes of practice if a collaborative agreement was required for prescriptive authority only, and full scopes of practice if no collaborative agreements were required."

Overall, the number of NPs in primary care practices markedly increased during the study period. The proportion of NP providers rose from 17.6% in 2008 to 25.2% in 2016 in rural areas, and from 15.9% to 23.0% in nonrural areas.

At the same time, the proportion of physician providers decreased from 69.4% to 60.5% in rural areas, and from 75.2% to 66.3% in nonrural areas.

Physician assistants comprised the smallest proportion of providers in the study, but also grew during the time from 13.0% to 14.4% in rural areas and from 8.9% to 10.8% in nonrural areas.

Scope-of-Practice Laws Not Limiting Uptake of NPs

In both rural and nonrural areas, NPs were most prevalent in states with full scope-of-practice laws. In these states, the percentage of practices with at least one NPs rose from 35.0% to 45.0% in rural areas during the study period, and from 26.5% to 36.0% in nonrural areas.

However, the fastest growth in NP presence occurred in states with reduced and restricted scopes of practice, the authors note.

In rural areas, the percentage of practices with at least one NP rose from 30.7% to 46.0% in states with reduced scopes of practice, and from 29.9% to 42.3% in those with restricted scopes.

Similarly, in nonrural areas, the percentage of practices with at least one NP rose from 17.4% to 27.6% in states with reduced scopes of practice, and from 17.4% to 25.8% in those with restricted scopes.

However, the researchers found no obvious association between state Medicaid expansion status and NP presence.

The results of this study not only support those of previous studies, the authors say, but also highlight practice-level trends in NP presence.

"Our findings imply that primary care practices are embracing a more diverse provider configuration, which may strengthen health care delivery overall," Barnes and colleagues conclude.

This study was supported by the National Institute of Nursing Research. The authors have disclosed no relevant financial relationships.

Health Aff. 2018;37:908-914. Abstract

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