Nurse Practitioners vs. Physicians: The Studies and Their Conclusions

Nurse Practitioners vs.  Physicians
Nurse Practitioners vs. Physicians

By 2030, 19% of the world’s population will be 65 and older. This growth is expected to cause a shortage of up to 120,000 physicians in the United States by 2030. Currently, the supply of such physicians cannot meet demand. In many parts of the country, nurse practitioners (NPs) are bridging the gap, providing expert care for diverse patient populations and myriad illnesses. Nurse practitioners are taking on more and more of the responsibilities traditionally handled by physicians. The increased reliance on NPs has accelerated an ongoing debate about the relative quality of NP care and cost savings in comparison to physicians.

I. NP vs. Physician

 

Nurse Practitioners

Doctors

Education

Bachelor’s in Nursing (BSN), Master’s degree in Nursing (MSN) is required, Doctor in Nursing Practice (DNP) is preferred.

MDs and DOs must earn a bachelor’s degree (e.g., pre-med, biology, chemistry, or another relevant area), and complete medical school, as well as a residency.

Timeline to Practice

2-3 years of graduate education and training. 6-7 years including BSN education

11 post-secondary years of education and training to become an MD or DO depending on specialty.

Typical Duties

- Obtaining a patient history and doing a comprehensive examination

- Ordering and interpreting diagnostic studies such as labs and x-rays

- Diagnosing and treating illnesses

- Managing a patient’s overall health by developing a plan of care

-Obtaining a patient history and doing a comprehensive examination

- Ordering and interpreting diagnostic studies

- Diagnosing and treating illnesses

- Managing a patient’s overall health by developing a plan of care

Can prescribe medications?

Yes. NPs prescribe medication in all 50 states. In some states, NP’s will need a physician collaborator to do so.

Yes. MDs and DOs can prescribe medications in all 50 states and DC.

Whereas an NP’s education comprises six-seven years of schooling, physicians have an average of 11 years of schooling. The impact of this difference on health outcomes has been examined for many years. A health outcome refers to the health status of a patient after medical treatment or a procedure. For example, mortality rates of cancer patients receiving chemotherapy would be a health outcome.

An overwhelming majority of studies that explore this issue compare the quality of care and relevant costs associated with NP care to that of physicians. Some of the common variables used in these studies are costs per visit, salaries, patients’ satisfaction, and overall health outcomes. There are also more nuanced studies that focus on illness-specific factors. For example, rather than assessing a patient’s overall satisfaction and life expectancy, a study on diabetes will measure hemoglobin A1c and levels of glucosamine tolerance to determine if NPs are more effective than physicians.

II. Quality of Care Studies

By focusing on general reports, illness-specific studies, and those that focus exclusively on distinct patient populations, the following section provides four short comparisons of the quality of NP care to that provided by physicians. A review of the literature and studies comparing NPs to physicians reveals that NPs provide a comparable or better quality of care. 

Study #1: Substitution of doctors by nurse practitioners in primary care 

Objective: Examine the impact of doctor-nurse practitioner substitution in primary care environments on the process of care and patient health outcomes. In order to evaluate the process of care factor, the study reviewed practitioner compliance with clinical guidelines and standards of quality of care. Patient health outcomes reviewed morbidity, mortality satisfaction, and compliance with standard operating procedures.

Scope of review: Studies in which nurse practitioners were compared to doctors who were providing a similar primary health care service (excluding emergency services). After reviewing 4253 articles of published reports, this study identified 16 studies that met the criteria for the comparison.

Outcomes: While the results of the study indicated very similar health outcomes for nurse practitioners and physicians, patients did express increased satisfaction with nurse practitioner-led care. After reviewing thousands of studies, the author concluded that “appropriately trained nurse practitioners can produce as high-quality care as primary care doctors and achieve as good health outcomes for patients.”

Study #2: Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial (2000)

Another study that examined the patient health outcomes of NPs and physicians identified a problem with prior comparisons of these two caregivers. Recognizing that prior comparisons failed to measure NPs who had the same level of autonomy as physicians, this study identified two sample sizes of caregivers with similar independence from supervisors.  

Objective: This study focused on outcomes for patients who were making appointments to follow up on a visit to the emergency room.

Scope of review: The study examined the experiences of 1316 patients who did not have a regular physician or NP. In order to determine the outcomes of patients treated by both, the study measured levels of patient satisfaction and their health status at different intervals of a one-year period following the initial appointment.

Outcome: Examination of the experience of 1316 patients revealed no significant differences in the patient’s health status or with patient satisfaction. In the conclusions drawn by the authors, the reports stated that “in ambulatory care situations where patients were randomly assigned to physicians and NPs with the same authority, the patient outcomes were comparable.”

Study #3: Provider Type and Quality of Outpatient Cardiovascular Disease Care (2015)

Whereas the first two studies examined the general performances of the two different caregivers, this study chose to compare the two groups within the specific context of cardiovascular disease care. 

Objective: Determine whether there are significant differences between the quality of care delivered by NPs and physicians in cardiology practices.

Scope of Review: 883 health care providers in 41 practices that treated 460,000 patients. Authors of the study performed a cross-sectional comparison of caregivers’ compliance with measures that are prescribed for treating heart failure and atrial fibrillation.

Outcomes: No significant differences between NP’s and physician’s compliance with measures for managing heart disease.

Study #4: Care of Nursing Home Residents by Advanced Practice Nurses (2008)

The fourth study focused on the experiences of patients in nursing homes.

Objective/Scope of review: This study, which was a literature review, screened articles about previous studies that took place over a 25-year period. 38 studies were included in the final review. While the studies varied in size and design, most examined issues related to the management of chronic conditions, functional improvements in the status of residents, mortality rates, and preventions of hospitalizations. 

Outcomes: The literature review uncovered several trends related to the management of chronic conditions, hospitalization rates, and mortality rates.

Managing chronic conditions: Eleven of the studies included in the review examined the impact of NPs on the management of chronic conditions. In each case, NPs “were found to provide equivalent or better management of chronic diseases such as hypertension, diabetes, and congestive heart failure.” For example, “in a study of three HMO plans comparing HMO care provided by physicians and NPs and fee-for-service care provided by physicians only, the study found that residents with NP services in the HMO model had improved disease management.” 

Reduced hospitalization: A 2004 study included in the literature review compared the ongoing impact of NP care to physician care for patients with heart disease, asthma, and diabetes. This statistical survey revealed that physicians “had a higher hospitalization rate than NPs and Physician Assistants (PA). More specifically, the study found that patients of physicians in nursing homes are more likely to be hospitalized than those who are cared for by NPs and PAs.

Impact on mortality rate: The comparative review of studies that focused on nursing home patients also reviewed mortality rates. The review revealed most studies found no difference between the mortality rates of nursing home patients that were cared for by physicians and those that were cared for by NPs.

III. Cost Reduction and Savings from NP Care As Opposed to Physician Care

In addition to confirming that NPs provide a comparable quality of care than physicians, a review of academic studies reveals that NPs also provide lower costs for patients. The studies on costs focus on the savings for patients and the reasons why NPs are able to charge less than physicians. The studies conclude that: 1) NPs’ fees for seeing patients are significantly lower than physicians and 2) NPs’ holistic approach provides preventive care that minimizes the necessary number of visits to a medical professional.

Lower education costs mean lower fees: One of the main reasons why NPs can charge less than physicians stems from the lower tuition rates they pay for their education. According to the American Association of Colleges of Nursing, the costs associated with preparing NPs for practice are 20% to 25% less than that of physicians. This savings is often passed on to the patient. Based in part of lower tuition fees, NPs can charge patients less than physicians for labor costs.

Whereas the average annual salary for an NP is $107,460, the average national salary for a physician is $299,000. NP cost-effectiveness is not exclusive to one practice setting. Savings related to NP care are found in primary and acute care settings.  A study that examined the NPs practicing in Tennessee’s state-managed care organization “delivered health care at 23% below the average cost associated with other primary care providers.”

IV. Preventive Care: Treating the Whole Patient Rather Than the Illness

Nurse practitioners are trained in preventive care that minimizes the need for doctor visits. Whereas physicians are trained to treat the illness/disease, nurse practitioners are trained to diagnose and treat the ways conditions afflict the patient. In short, the NPs address the patient’s holistic healthcare needs. For example, this includes prescribing medicine and advice on diet and exercise when examining the ways a specific condition might impact the patient. 

A report that appeared in the journal called Health Affairs encapsulated the value added by NPs in the primary care context: “the patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.” Ultimately, the comprehensive treatment of the whole patient--rather than the specific illness--mitigates the need for frequent visits for medical care.

Results from a one-year study that compared a physician-managed family practice to one managed by NPs are instructive. Patients of NPs required a fraction of the care that was provided to those of physicians: 43% of the total emergency department visits, 38% of the inpatient days and 50% of total annualized per member monthly cost.

V. An argument for increasing the scope of practice for nurse practitioners

Recent reports conclude that state regulations for NPs do not have a net positive effect on health outcomes. Authors conclude that legislators should remove barriers to NP autonomy.

Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes

Objective: Measure the effects of state regulation for NPs on health outcomes.

Method: This study compared the healthcare outcomes of Medicare beneficiaries of Rural Health Clinics (RHC) located in states with minimal regulations for NPs to those with very restrictive laws. This study analyzed data from a sample of Rural Health Clinics (RHCs) located in eight Southeastern states. Independent tests were performed for each of the five variables to compare patient outcomes of the experimental RHCs.

Outcomes: Among the 77 RHCs with 90% or more NPs, two groups were created: RHCs in reduced practice states (the experimental group), and RHCs in restricted practice states (the comparison group.) According to this study, there are strong indications that the quality of patient outcomes is not reduced when the scope of practice is expanded. Moreover, it is important to stress that “populations derive other benefits when NP scope of practice is less restrictive.”

In states where legislative barriers significantly impair the ability of NPs to practice with autonomy, some legislators are trying to change the regulatory landscape. For example, in Texas, a state representative filed a bill in the state’s House to provide NPs with more authority. House Bill 1792 aims to increase the scope of practice for NPs by authorizing them to order, perform and interpret diagnostic tests, formulate primary and differential medical diagnoses and advanced assessments and treat actual/potential health problems.

Baylor University's Louise Herrington School of Nursing Online helps experienced nurses take the next step as NPs. This DNP program allows nurses to complete coursework on their time through online courses. Baylor University does not require DNP applicants to complete the GRE or GMAT exams. After completing core coursework, you can finish the doctoral residency and final project in your community without heading to Baylor’s Waco campus.

Conclusion

A review of comparative research reveals that NPs provide exceptional quality of care that is equal to or better than that of physicians. Moreover, studies clearly indicate that the employment of NPs significantly reduces conventional health care costs. The conclusions drawn from these studies are reinforced by the systematic studies of health outcomes, which are comparable or better in states that foster the autonomy of NPs. These three factors should compel legislators to remove regulatory barriers affecting NPs in order to address the provider shortage and limit the financial strain on our healthcare system.