Increasing Non-Physician Practitioners’ Role in Emergency Room Care. Is that a Good Thing?
A recent article on Medscape.com tells of an issue physicians have been worrying about for decades. In rushing to fill staffing gaps, states and non-physician owned organizations seem to act under the misguided impression that physician extenders—professionals like advanced registered nurse practitioners (ARNPs) and physicians’ assistants (PAs)—can substitute for fully trained doctors in the evaluation, diagnosis, and treatment of patients.
For physicians, these personnels’ shortcomings are obvious because they continuously come across them: patients wrongly diagnosed by “physician substitutes”, evaluated using unnecessary or inappropriate studies, and the use of unsubstantiated pathophysiological concepts to explain sometimes-incorrect diagnoses.
Increasingly, non-physicians are directing the care of patients at our nation’s hospitals.
Despite these consistent and recurrent impressions by physicians, both state governments and non-physician-based organizations tend to believe the ARNP or the PA are acceptable and less expensive substitutes for the work of an adequately trained doctor. In few specialties is the encroachment more apparent than in the emergency room.
In 1997, 5.2 million visits involved nonphysician practitioners (NPPs) while in 2018, NPPs were involved in 35.3 million emergency room visits.[i] This near 7-fold increase compares overwhelmingly with a 1.2 increase in emergency room visits per 1000 people in the same timeframe.[ii]
The pressures causing this trend rests upon only one issue: money. The salary for a physician hovers at around $310,000.00 per year compared to $120,000.00 for a PA. Of course, those making the decision to substitute a physician for an NPP get what they pay for.
Training a physician to work in the emergency room requires, at the very least, four years of college education, four years of medical training, and three years of post-graduate training. NPPs, on the other hand require at least four years of college education and a single post-graduate education year. One would think that the differences in outcomes from the two groups would be easy to differentiate, but until recently, demonstrating such variations in outcomes have been difficult to show. The major issue in the past was that the literature was inundated with studies demonstrating no appreciable differences between the care provided by NPPs and physicians.[iii],[iv],[v]. In part the reason for this was that NPP advocates such as the American Association of Nurse Practitioners were funding studies demonstrating “no statistical difference” between the care provided by ARNPs and physicians. In fact, their studies often claimed that the ARNP’s performance often exceeded that of a physician’s. A closer look at those studies, however, demonstrated obvious flaws in the techniques and methods used to deliver their data. Nevertheless, due to the absence of convincing contrarian evidence, politicians and policymakers ran to these lesser-trained options to fill in the gaps in the healthcare provider shortages they were identifying. Similarly, for profit-motivated organizations such as some private equity investors substituting the physician with the “equivalent” NPP made economic sense.
However, the negative impacts of relying on NPPs for the delivery of care are now starting to appear. A study cited by Medscape demonstrated a 5.3% increase in the use of imaging studies amongst NPPs relative to physicians caring for patients in the emergency room. The same study also found poorer performance in quality-of-care measures by NPPs relative to physicians. These patients were found to have a 20% higher chance of being readmitted to the hospital within 30 days of the initial visit, and the cost of care increase to the facility stood at about 7%.
Simply put what the literature is beginning to show, and the organizations are beginning to realize, is that hiring more qualified medical professionals who are specifically trained to attend to emergency room patients translates to greater quality of care to the patient, more efficiency to the facility, and lower out or pocket expenses per patient. Yes, there are roles for physician extenders in healthcare delivery, but ultimately, these professionals are extenders, not substitutes for well-trained physicians. The sooner policymakers and corporate executives accept this seemingly obvious fact, the sooner we can make progress at improving the safety and efficacy of our emergency rooms.
[i] Christensen EW, Liu C, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open. 2022;5(11):e2241297. doi:10.1001/jamanetworkopen.2022.41297
[ii] Ibid.
[iii] Carranza AN, Munoz PJ, Nash AJ. Comparing quality of care in medical specialties between nurse practitioners and physicians. J Am Assoc Nurse Pract. 2020 May 6;33(3):184-193. doi: 10.1097/JXX.0000000000000394. PMID: 32384361.
[iv] Martínez-González NA, Djalali S, Tandjung R, Huber-Geismann F, Markun S, Wensing M, Rosemann T. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014 May 12;14:214. doi: 10.1186/1472-6963-14-214. PMID: 24884763; PMCID: PMC4065389.
[v] Peeters MJ, van Zuilen AD, van den Brand JA, Bots ML, van Buren M, Ten Dam MA, Kaasjager KA, Ligtenberg G, Sijpkens YW, Sluiter HE, van de Ven PJ, Vervoort G, Vleming LJ, Blankestijn PJ, Wetzels JF. Nurse practitioner care improves renal outcome in patients with CKD. J Am Soc Nephrol. 2014 Feb;25(2):390-8. doi: 10.1681/ASN.2012121222. Epub 2013 Oct 24. PMID: 24158983; PMCID: PMC3904557.
