Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the comparative effectiveness of primary care provided by independent family nurse practitioners when compared to family practice physicians when the two provider types have similar authority to practice and groups are controlled for similar years of post graduate experience (with residency included in calculation of post-graduate experience).

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

The Family Nurse Practitioner model is based in the nursing approach of treating the entire patient including consideration of factors not traditionally addressed by the medical model of care like financial status, environmental factors, psychosocial considerations, patient education, and lifestyle modification. The literature has several studies comparing NP care to physician care that measure safety and efficacy of care in terms of the medical model but few, if any, address the nursing model of care versus the medical model of care in large groups over extended period of time. this is particularly important to rural patients who are historically underserved and whose access to care has been improved by the presence of NPs.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Rural primary care recipients. groups that are of particular interest include those in which lifestyle modification, patient education, and psychosocial issues have significant influence over morbidity and mortality including - DM, COPD & asthma, HTN, CAD, and their associated sequelae, as well as those with chronic conditions and functional limitations being managed at home.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

undifferentiated rural patients presenting to establish a primary care relationship with a provider.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Benefits of such a comparative effectiveness study include demonstration or refutation of the need for medical "collaboration" or "supervision" of NP practice. If NP practice and the nursing approach to care is demonstrated as effective as, or more effective than, the medical model of care then policies that limit access to care based on provider type or requirements for "collaboration" or "supervision" can be re-evaluated objectively by policy makers in the absence of undue economic influence.

Describe any health-related risks, side effects, or harms that you are concerned about.

Risks include identifying potential lower quality of care in one of the groups and associated public concern that one group significantly out performs the other. Stakeholder groups include the AMA and AAFP whose members have a financial interest in not comparing quality of independent FNP practice with family practice physician practice and the AANP and ACNP whose members have a financial interest in comparing the two practice approaches. Given 40 years of studies, with variable power, showing safe and effective care of FNPs using the medical model of care with no study showing lower quality than family practice physicians - harm, risks, and side effects to the patient are minimal while financial and prestige side-effects to physicians may be substantial.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

None

AHRQ Priority Populations

None

Federal Health Care Program

None

Importance

Describe why this topic is important.

Rural populations are historically underserved by physicians and that nurses have provided primary care services safely and effectively in rural and underserved areas with little, if any, "supervision" from the medical community. In some cases "supervision is a single chart review every two weeks to meet FQHC rules, for which the physician is paid as a "medical director" - while physician groups (AMA & AAFP) publically claim "quality concerns" for those NPs who provide care independently. This process of "supervision" applies to private and public third party payers resulting in a convoluted billing structure which in turn discourages FNPs from independently providing care in otherwise rural and underserved communities. The only benefactors from such a system are the third party payers who reimburse at a lower rate for FNP care while the FNP is held to an equal standard of care as the physician (Fein v. Permanente, Cal. 1985) and the physician who receives payment for acting as a "medical director" without providing any value to the patient. Those who are disadvantaged include patients who are faced with decreased access to care related to practice distribution of NPs mirroring the physicians they are frequently employed by (to avoid the billing nightmare current rules require) and FNPs who prevented from providing care within the nursing model related to rules set by "supervising" physicians.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

While in an NP program I discovered that while 40 years of research into the safety and efficacy of NP care has been conducted, there is a public perception that NPs provide a lower quality of care or cannot provide care outside of a "cookbook approach" dictated by a physician.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

there is uncertainty among policy-makers as to the quality of care provided by NPs as evidenced by requirements for "supervision" or "collaboration" in several states and at the federal level while no evidence as to the need for such "supervision" exists. frequently NPs are grouped with PAs as "midlevel" providers and grouped with PAs for "supervision" requirements even though training, approach to care, and supervision requirements are significantly different.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Removal of barriers to independent NP practice in primary care will potentially improve access to patients in rural and underserved areas.

Describe the timeframe in which an answer to your question is needed.

Given the 40 year history of the NP and the nature of comparison, a 10 year, or longer, longitudnal study would provide the answer.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

This question applies to rural populations and othe medically underserved areas and populations.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Removal of barriers to independent NP practice in primary care will potentially improve access to patients in rural and underserved areas.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

None