Assuring quality and access in advanced practice nursing: a challenge to nurse educators.

In an environment characterized by a projected over-supply of primary care providers and a public seeking higher quality, cost-effective care, advanced practice nurses will be measured not only by their comparative value in delivering conventional primary care, but also by the uniqueness of their contributions to health outcomes. These value-added skills, distinctive to nursing practice at all levels, include health education, disease prevention, health promotion, community resource access, and partnerships with patients. Government, private payors, and national and state regulators all authorize increasingly independent practice by advanced practice nurses. When advanced practice nurses assume such fully accountable primary care roles, their title and certification should be distinctive to that level of practice. A Doctor of Nursing Practice (DNP) degree would signal to the public that nurses--at their highest practice competency--are at the same level as other health professionals holding doctorates (such as MD, DDS, or PharmD).

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.

CONTEXT: Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. OBJECTIVE: To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. DESIGN: Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. SETTING: Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. PATIENTS: Of 3397 adults originally screened, 1316 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 a nurse practitioner (n = 806) or physician (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 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. RESULTS: No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). CONCLUSIONS: In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

Health care trends, Part 2. The new health care team. Panel discussion.

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.

Can advanced practice nurses succeed in the primary care market?

In the mid-1980s the Columbia University School of Nursing (CUSN) reconfigured its mission to once again become the premier training ground for clinical experts in nursing. Its APN faculty members were expected to function as APN primary care providers in some of its affiliated clinics. Extensive studies at CUSN have validated the high quality and effectiveness of comprehensive APN-managed patient care when compared to a randomly selected group of patients managed by primary care MDs. The issue of APN-MD primary practice fee equity for professional services at Columbia Presbyterian Medical Center was settled by agreement to the same reimbursement per visit, while acknowledging that APNs would customarily have longer contact time with each patient, and therefore a lower number of visits per day. The studies concluded that the ideal configuration of professional health care services would see APNs with hospital admitting priviledges alongside primary care and specialty MDs working collectively to serve their patients together in the new system.

Differentiated primary care and evidence-based practice: the Columbia nursing experiment.

Changes in our health care system and the growth of managed care have turned the spotlight on primary care and are driving sweeping reforms in health professions education, patient care, and research. The Columbia University School of Nursing has responded to this challenge by establishing a community primary care clinic managed by nurse practitioners. This article describes this clinic, an evaluation study of this practice, and their relevance to pending policy discussions on primary care provider designation and payment and the regulation of scope of professional practice.

New alliances: nursing's bright future.

The health care system is undergoing tremendous change. Managed care and its several incentives probably represent only an intermediate step in an unstable evolution. Equilibrium will no doubt appear with new alliances, particularly between medicine and nursing. Nurses and physicians charting a path of collaboration will ensure patients a broader set of services and high-quality care.