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A working paper that's likely to spur debate found that nurse practitioners (NPs) used more resources and had worse patient outcomes compared with physicians in the emergency department (ED), and will be the focus of a panel discussion at the American Medical Association's (AMA) state advocacy meeting next month.

The paper, which was released to little fanfare in October and has not been peer-reviewed, found that when patients received care from NPs in the ED, their length of stay increased by 11% (18 minutes per visit) and their cost of care increased by 7% ($66 per visit) compared with patients treated by physicians.

NP care in the ED was also associated with an 20% increase in 30-day preventable hospitalizations, according to David C. Chan Jr., MD, PhD, of Stanford University in California, and Yiqun Chen, PhD, of the University of Illinois Chicago.

This findings, they suggested, "may reflect two possibilities." Either that "NPs have poorer decision-making over whom to admit to the hospital, resulting in under-admission of patients who should have been admitted and a net increase in return hospitalizations, despite NPs using longer lengths of stay to evaluate patients' need for hospital admission," or that "NPs produce lower quality of care conditional on admitting decisions, despite spending more resources on treating the patient (as measured by costs of the ED care). Both possibilities imply lower skill of NPs relative to physicians."

Chan and Chen noted that this research suggests that NPs are less cost-effective when practicing independently of physicians and that "even under the most conservative assumptions, the resource costs implied by the lower productivity we find outweigh any salary savings from hiring NPs, despite NP wages that are half as much as physician wages."

However, they did acknowledge that the "performance gap between NPs and physicians narrows as NPs gain more experience, suggesting that differences in training could explain some of the gap."

The AMA praised the study for its focus on the importance of keeping physicians in the care team model and said in a statement provided to 麻豆传媒 that the findings reinforced that "nurse practitioners are not a replacement for physicians."

"This should raise alarm bells for lawmakers and others considering expanding the scope of practice of nurse practitioners," the AMA statement continued. "Removing physicians from the care team leads to higher utilization of healthcare resources, increased spending, and lower quality of care."

The AMA also emphasized that the paper added to "a growing body of research" that shows that "physician-led teams achieve high-quality patient care, while reducing costs."

The paper will be featured as part of entitled "Scope of practice: The value of data to drive policy" during the AMA's State Advocacy Summit, held in Marana, Arizona, on January 12-14.

But in a statement provided to 麻豆传媒, leadership of the American Association of Nurse Practitioners (AANP) highlighted several concerns about the paper, including the fact that it was not peer-reviewed.

"The recently released working paper is based on a very small sample size, in a single work setting and is not an accurate representation of NP practice or value," April Kapu, DNP, president of the AANP, said. "Each year, NPs across the nation deliver high-quality healthcare in more than 1 billion patient visits. Meeting the nation's healthcare needs requires all of us."

The AANP also noted that the research supporting NPs' productivity and health outcomes goes back 50 years and directly contradicts some of the paper's findings, showing that NP care is both and .

"For decades, NPs have been providing high-quality care to patients across the lifespan in nearly every healthcare setting," Kapu said. "NP care is safe and cost-effective, with studies finding significant savings for patients with complex and chronic conditions. As the healthcare industry faces unprecedented workforce shortages and increasing healthcare needs, NPs are and will continue to be vitally important to patients' access to high-quality healthcare."

Chan and Chen analyzed the two professions using data from the Veterans Health Administration because NPs were granted full practice authority in December 2016, which allowed them to practice without physician supervision.

To analyze the effects of that decision, the researchers used a sample of 1.1 million ED visits from January 2017 to January 2020 of patients arriving during similar times and used a quasi-experimental variation in the patient probability of being treated by physicians versus NPs.

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