Wading Into the National Debate Over the Delivery of Primary Care: A Basis for Optimism

MD and NP applaud steps to define the concept of primary care in JAGS co-authored editorial; call for better data, measures to help achieve best outcomes for older adults with chronic illnesses

MD and NP applaud steps to define the concept of primary care in JAGS co-authored editorial; call for better data, measures to help achieve best outcomes for older adults with chronic illnesses.

Newswise, January 11, 2016 — There is an ongoing national debate, heated at times, amongst health professionals concerning nurse practitioners (NPs) taking on the role of primary care physicians (MDs).

An increasing number of states have been allowing NPs with advanced degrees to practice without the direct oversight of an MD, effectively allowing NPs to be the sole provider of primary care.

Such legislation has been the response to a general shortage of primary care physicians, especially in rural areas.

In a recent issue of the Journal of the American Geriatrics Society (JAGS) [Vol. 63, #10, October 2015], the lead article, “Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians,” by Yong-Fang Kuo, PhD, compares processes and cost of care among older diabetes patients cared for by NPs versus MDs in a retrospective cohort study.

Alongside the study, JAGS’ editors also chose to publish a commentary editorial entitled “The Eye of the Beholder,” authored by Dr. Robert Kane, MD, School of Public Health, University of Minnesota, and Eileen M. Sullivan-Marx, PhD, RN, College of Nursing, New York University.

Kuo and his colleagues, utilized data from patients with a diagnosis of diabetes in 2009 (n=64,354) who received all their primary care from NPs or MDs, selected from a national sample of Medicare beneficiaries.

They concluded that compared to MDs, NPs were either similar or slightly lower in their rates of diabetes guideline concordant care. NPs used specialist consultations more often but had similar overall costs of care to MDs.

“The basic message is that the original study found a very small difference that was statistically significant because of very large sample sizes from an administrative data base,” said Dr. Kane. “Pragmatically the results suggest no clinically important difference.”

“This is a case of cup perspective—an example of the phenomenon of point of view,” notes Sullivan-Marx. “Kuo and his team use these findings to suggest that the quality of care that NPs provide is less than that of physicians, but the performance seems similar.”

“At the very time when society faces a boom in chronic disease, there is a bust in primary care,” Sullivan-Marx adds. “NPs represent an important resource to help address this imbalance.”

Dr. Kane and Sullivan-Marx note that the Kuo study limits the definition of “primary care provider” by stipulating that care be provided by only one type of practitioner.

Such a definition marginalizes the idea that primary care can be a collaborative effort between practitioners, and “what we do know about diabetes care,” says Dr. Kane, “is that personal engagement, use of teams of caregivers, including nutritionists, leads to better overall patient outcomes.”

Dr. Kane and Sullivan-Marx stress that the concept of primary care remains elusive, but not unattainable.

“Efforts to use the best available administrative data to identify processes and outcomes of primary care have been frustrating, particularly so for older adults with complex chronic illnesses,” admitted Sullivan-Marx.

“The data are incomplete in these databases, and incomplete data can be misleading.”

“Sadly, the range of concerns underlying today’s concept of coordinated, continuous, comprehensive primary care gets lost on specialists, who too often are delivering the bulk of the care to many older people.” said Dr. Kane.

“At a time when it is a struggle to fill the primary care gap, NPs should be viewed as valued partners.”

“Kuo et al. have embraced the challenge to ascertain answers to these important questions using available, if incomplete data,” concludes Dr. Kane and Sullivan-Marx, “leaving us to recognize that better data and better measures are needed to understand how to achieve the best outcomes.”