NPs Match Physicians in Prescription Safety in New Study

• A new study in the Annals of Internal Medicine compared the inappropriate prescription rates of nurse practitioners (NPs) and physicians and found them equal at 1.7%.
• This supports the idea that nurses be responsible for a patient’s full care without compromising safety but also suggests safeguards for all prescribing clinicians.
• An NP’s ability to practice independently, also known as their authority can be broken down into three levels, full practice, reduced practice, and restricted practice.

Collaboration in healthcare teams is essential to providing the best care for patients. However, as primary care physicians face continued staffing shortages, more conversations are being had about a nurse’s place as an independent clinician.

A recent study found that nurse practitioners (NPs) share the same rates of inappropriate prescribing as physicians (at about 1.7%). The authors of this study believe there is growing evidence that nurses pose no increased risk when granted prescription authority.

Allowing NPs independence may benefit patients in rural areas who have less access to primary care physicians. Prioritizing nurses in all parts of a patient’s care may also benefit their holistic well-being, as nurses are often the most involved in the direct care of patients.

This article will explore the recent study on inappropriate prescribing and the current environment for NPs who want independent authority over their own practice.

Inappropriate Prescribing: Nurse Practitioners vs Physicians

On October 24th, the Annals of Internal Medicine published a study titled “Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians.”

This study compares inappropriate prescribing rates from nurse practitioners (NPs) and physicians across 29 states. It included nearly 75,000 NPs and physicians who wrote prescriptions for over 100 patients a year. 

The average rates of inappropriate prescribing for NPs and physicians were nearly identical at 1.66 vs 1.68 per 100 prescriptions. A prescription was considered inappropriate if the American Geriatrics Society’s Beer Criteria defined the drug prescribed as atypical for adults over the age of 65.

The American Geriatrics Society (AGS) Beers Criteria has been utilized since 2011 to categorize potentially inappropriate medications (PMIs) for adults over 65. Medications are sorted into the following five categories:

1. Medications considered Potentially Inappropriate
2. Medications Considered Potentially Inappropriate for Patients with Certain Diseases or Syndromes
3. Medications to be Used with Caution
4. Potentially Inappropriate Drug Interactions
5. Medications that Should Have Adjusted Dosages Based on Renal Function

While this study found no significant difference in the inappropriate prescription rate of NPs and physicians, it did find a wide variation across both groups. David Studdert, a senior researcher at Stanford University and co-author of this study, stated that less focus should be put on whether or not NPs should be allowed to prescribe medications to patients and instead put towards how to make improvements across ass prescribers.

Another co-author, Johnny Huynh, stated that “NPs were over-represented among the best performers and the worst performers.” The study described several interventions that aim to improve prescribing across all clinicians, including prescription drug monitoring systems and better adherence to the AGS’s Beers Criteria’s guidelines.

NPs Role in the Healthcare Shortage

Along with the national nursing shortage in the U.S., there is also a growing shortfall of primary care physicians. This has led to states granting nurse practitioners and other providers more authority in their practice.

There has been some pushback  from groups such as the American Medical Association (AMA), which consider this “scope creep” a danger to patients and have worked to block any legislation granting independence to APRNs and other clinicians.

One argument the AMA makes is that physicians are more qualified due to their increased clinical training. However, one study of over 19,000 physicians in the U.S. found that 70% of family physicians may spend less than 24 minutes with a patient, and 67% of pediatricians spend less than 16 minutes with a patient.

Another study found that physicians spent 15% of their time in a patient’s room compared to nurses 33% of their time in a patient’s room. It is not difficult to see why qualified nurses may also have insight into what’s best for patients.

NPs Role in the Healthcare Shortage

Practice Authority for Nurse Practitioners

The scope of authority for clinicians can be broadly categorized into three categories; full practice, reduced practice, and restricted practice. Organizations like the AMA campaign to ensure nurse practitioners work in reduced or restricted practices. 

Full Practice

Full practice allows nurse practitioners to work independently without a supervising physician. These nurses can diagnose patients, order tests, prescribe medications, and run their own practices. The process of establishing full practice authority varies from state to state, as some may require specific training or experience working under a physician before granting full practice authority.

The following states and territories allow NPs full practice authority:

1. Alaska
2. Arizona
3. Colorado
4. Connecticut
5. Delaware
6. District of Columbia
7. Florida
8. Guam
9. Hawaii
10. Idaho
11. Iowa
12. Kansas
13. Maine
14. Maryland
15. Massachusetts
16. Minnesota
17. Montana
18. Nebraska
19. Nevada
20. New Hampshire
21. New Mexico
22. New York
23. North Dakota
24. Northern Marina Islands
25. Oregon
26. Rhode Island
27. South Dakota
28. Utah
29. Washington
30. Wyoming

Reduced Practice

Reduced practice restricts the scope of a nurse practitioner’s practice by limiting their ability to prescribe medication or run their own practice. These nurses are also rarely allowed to order tests or diagnose their patients,  often working in offices supervised by a physician.

The following states and territories allow NPs reduced practice authority:

1. Alabama
2. American Samoa
3. Arkansas
4. Illinois
5. Indiana
6. Kentucky
7. Louisiana
8. Mississippi
9. New Jersy
10. Ohio
11. Pennsylvania
12. Puerto Rico
13. S. Virgin Islands
14. West Virginia
15. Wisconsin

Restricted Practice

Restricted practice means that nurse practitioners are unable to have any independence in their practice. These nurses must work under the supervision of a physician with some possibility of loosened restrictions as the nurse gains experience.

The following states and territories allow NPs restricted practice authority:

1. California
2. Georgia
3. Michigan
4. Missouri
5. North Carolina
6. Oklahoma
7. South Carolina
8. Tennessee
9. Texas
10. Vermont

The Bottom Line

States continue to debate the place of independent nurses as leaders in patient care, with patient safety always at the highest priority. However, studies like this one showcase the important role NPs could play in providing primary care to patients who would otherwise not have any clinician accessible to them.

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