2/6/02 Nurse Practitioners: A (Not So) New Role in Health Care Kathleen Dracup, RN, FNP, DNSc Dean and Professor School of Nursing University of California, San Francisco

2/6/02 Who are Advanced Practice Nurses? Masters prepared Registered Nurses: –Nurse practitioners (NP) –Clinical nurse specialists (CNS) –Combined (NP/CNS) –Certified Nurse Midwives (CNM) –Certified Nurse Anesthetists (CNA)

2/6/02 RNs prepared for APN DHHS, March 2000

2/6/02 History of the Nurse Practitioner Social phenomena of the 1960’s provided impetus for NP movement –Shortages of pediatricians and family practice MDs –Lack of primary health care for rural areas and urban poor –Escalating health care costs –RNs desire to attain autonomy 1st NP program – U of CO as a research program

2/6/ HEW proposed definition of primary care: –A person’s first contact in any given episode of illness with the health care system that leads to a decision of what must be done to help resolve the problem –Responsibility for the continuum of care (maintenance, evaluation, management) –MDs & RNs should share responsibility for primary care

2/6/02 NPs today NPs practice independently (i.e., without MD supervision or collaboration) in the majority of states In all states, NPs have independent prescribing authority Reimbursement for primary care services: –Medicaid/MediCal/MediCare Part B –Commercial insurance Hospital admitting privileges

2/6/02 Numbers 103,000 NPs in U.S. 9,500 NPs in California Graduates of UCSF NP programs from = 1,000

2/6/02 Is a PA like an NP? PA –“Physician extender” –Must practice under supervision and license of MD –MD is liable for acts of PA under their direction NP –Complements MD –Functions under own license –Education is more extensive –Scope of practice is broader

2/6/02 Viva la difference!? Training Licensing Medical vs. Nursing Model Scope of practice

2/6/02 Training M.D. –B.S. (pre-med) –Medical School (4 yrs) –Internship (1yr) –Residency (varies) Nurse Practitioner –B.S. (Nursing/RN) –Masters Degree (2-3 yrs) didactic/clinical (internship) –other specialty training (varies)

2/6/02 Licensing MD –medical Board exam –specialty exams APN –nursing Board exam –NP exam/certification

2/6/02 Model of Care MD “medical model” curing RN “nursing model” caring

2/6/02 Scope of Practice NP – Nurse Practice Act –Primary health promotion –Disease prevention –Assessment/diagnosis and management of common illness and chronic stable conditions –Use of ‘standardized procedures’ –Expanded roles for specialty care

2/6/02 NPs “NPs may order, conduct, and interpret appropriate diagnostic and laboratory tests and prescribe pharmacologic agents, treatments, and non-pharmacologic therapies. Educating and counseling individuals and their families regarding healthy lifestyle behaviors are key components of NP care” Porcher, F. K. (1996). Advanced practice nursing ( )

2/6/02 Patient education and counseling Moody et al, NP, 1999, 24(3):94-103

2/6/02 Comparison of top five NP & MD principal diagnoses MD –Hypertension –Normal pregnancy –Acute upper respiratory infection –Otitis media –Health exam NP –Health exam –Hypertension –Routine child health –Otitis media –Acute upper respiratory infection Moody et al, NP, 1999, 24(3):94-103

2/6/02 Common diagnostic or screening tests Moody et al, NP, 1999, 24(3):94-103

2/6/02 What counts: Patient outcomes NPs can effectively treat 90% of all pediatric patients and 80% of all adult patients. Outcomes are equal to or better than care by physicians. »(Office of Technology Assessment, 1987)

2/6/02 What counts: Patient outcomes NYC  2000 patients randomized to MD or NP serving as primary care provider –Little or no difference in health status, disease specific physiologic measures, patient satisfaction, resource utilization (Mundinger et al, JAMA, 2000)

2/6/02 More outcomes Meta-analysis of 38 studies comparing NP/CNM and MD (Brown & Grimes, ANA, 1993) –Number and cost of drugs similar between MD and APN –More lab tests ordered by APN but cost 8% less –Patient knowledge similar –APNs received higher scores on Resolution of pathologic conditions Patient satisfaction Functional status Patient compliance –Average number of visits similar but fewer hospitalizations for patients seen by APNs

2/6/02 Cost/Benefit Reduced educational opportunities for residentsReduced educational opportunities for residents Reduced interaction of physician with patient/familyReduced interaction of physician with patient/family Reduced hospital length of stayReduced hospital length of stay Fewer complicationsFewer complications Improved patient satisfactionImproved patient satisfaction Less litigationLess litigation

2/6/02 Patients and their healthcare provider

2/6/02 Patients’ Active Involvement in Care (n = 27 patients with heart failure) At the most recent physician visit, 5 asked doctor about other medications they could take for heart failure 3 brought written information to the visit 2 wrote questions on paper and took to the visit How Active Are You In Making Decisions with Your Doctor about Your Health Care How Active Would You Like to be in Making Decisions with Your Doctor about Your Health Care Bennett, ‘PUMP-UP’

2/6/02 Patients and their healthcare provider More patient control More emotional display by both MD and patient More effective information gathering by patients More conversation by patients relative to the MD = better health status (functional & subjective) at follow-up Kaplan, Greenfield, Ware. Med Care 1989

2/6/02 Make the most of your visit Be prepared! –Bring list of medications, treatments, concerns, questions; know your family history Don’t be afraid to talk. The more you ask, the better your health. If you are nervous, say so. Don’t feel rushed. If you have a question, ASK IT. If you don’t understand something, ASK. Participate in decisions, especially major ones. Negotiate decisions if need be.