Opioid Prescribing by Nurse Practitioners in Medicare Part D: Impact of State Scope of Practice Legislation

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

Influence of provider type on chronic pain prescribing patterns A systematic review

BACKGROUND

Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues.

OBJECTIVE

Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist.

DATA SOURCES

Searches within PubMed, Embase, CINAHL, and Web of Science.

CONCLUSIONS

Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines.

IMPLICATIONS FOR PRACTICE

Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.

Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing

Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states.

CONTEXT

As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids.

METHODS

This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers.

FINDINGS

Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs.

CONCLUSIONS

No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.

Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers

OBJECTIVE

To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type.

METHODS

We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims.

RESULTS

From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by -5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period.

CONCLUSIONS

From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

Assessing Practice Patterns and Influential Factors for Nurse Practitioners Who Manage Chronic Pain

INTRODUCTION

Challenges exist in caring for chronic pain patients, such as preventing opioid-related adverse events, a lack of available non-pharmacologic alternatives, and limitations in prescriptive authority. Nurse practitioners are well-suited to manage chronic pain due to their holistic approach to care and growing numbers in primary care. Yet little is known about the chronic pain care given by NPs. As such, the purpose of this study was to understand the experiences of NPs who manage chronic pain, and to examine how these experiences impact NP prescribing patterns in chronic pain management.

METHODS

We developed the 31-item NP Chronic Pain Prescribing Practices survey. We collected data from N = 128 NPs at the American Association of Nurse Practitioners (AANP) conference. Pearson chi-square and Fisher's exact tests were utilized for statistical analysis.

RESULTS

NPs reported high levels of agreement with nearly all the presented challenges. MSN-prepared NPs were more likely than DNP-prepared NPs to report difficulty in managing pain (x 2 = 4.2, p = .04). There were no differences in prescription of chronic pain therapies between NPs of varying practice authority statuses. NPs in specialty care settings were more likely to utilize opioids (x 2 = 13.6, p < .01), while primary care NPs were significantly more likely to use NSAIDs (x 2 = 13.5, p < .01) and Tylenol (x 2 = 3.9, p = .05).

CONCLUSIONS

Our findings demonstrate significant challenges NPs face in chronic pain management. More research is needed to better understand the complexities associated with chronic pain care given by NPs in order to effectively manage chronic pain while still preventing opioid-related adverse events.

Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care

BACKGROUND

Nonadherence to medications is costly and improving adherence is difficult, requiring multifactorial solutions, including policy solutions.

OBJECTIVE

The purpose of this study is to evaluate the effect of one policy strategy on medication adherence. Specifically, we examine the effect on adherence of expanding scope-of-practice regulations for nurse practitioners (NPs) to practice and prescribe without physician supervision.

DESIGN

We conducted three difference-in-difference multivariable analyses of commercial insurance claims.

PARTICIPANTS

Patients who filled at least two prescriptions in one of three chronic therapeutic medications: anti-diabetics (n = 514,255), renin angiotensin system antagonists (RASA) (n = 1,679,957), and anti-lipidemics (n = 1,613,692).

MAIN MEASURES

Medication adherence was measured as the proportion of days covered (PDC). We used one continuous (PDC 0-1) and one binary outcome (PDC of > .8), the latter indicating good adherence.

KEY RESULTS

Patients taking anti-diabetic medications had a 1.9 percentage point higher medication adherence rate (p < 0.05) and a 2.7 percentage point higher probability of good adherence (p < 0.001) in states that expanded NP scope-of-practice. Medication adherence for patients taking RASA was higher by 2.3 percentage points (p < 0.001) and 3.4 percentage points (p < 0.01) for both measures, respectively. Patients taking anti-lipidemics saw a smaller, but statistically insignificant, improvement in adherence.

CONCLUSIONS

Results indicate that scope-of-practice regulations that allow NPs to practice and prescribe without physician oversight are associated with improved medication adherence. We postulate that the mechanism for this effect is increased access to health care services, which in turn increases access to prescriptions. Our results suggest that policies allowing NPs to maximally use their skills can be beneficial to patients.

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BACKGROUND

Nursing brings a unique lens to care of patients with pain and opioid misuse.

AIMS

This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.

DESIGN

The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

DATA SOURCES

Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.

ANALYSIS METHOD

Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature.

RESULTS

Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).

CONCLUSION

Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.

IMPLICATIONS FOR NURSING

This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns

BACKGROUND

Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs).

OBJECTIVE

To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs).

DESIGN

Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data.

PARTICIPANTS

Twenty percent national sample of 2015 Medicare Part D enrollees.

MAIN MEASURES

We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients.

KEY RESULTS

Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states.

CONCLUSIONS

Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.

The relationship of nursing practice laws to suicide and homicide rates: a longitudinal analysis of US states from 2012 to 2016

BACKGROUND

Nursing resources can have a protective effect on patient outcomes, but nurses and nursing scope of practice have not been studied in relation to injury outcomes. The purpose of this study was to examine whether scope of practice and ease of practice laws for nurse practitioners and registered nurses are associated with suicide and homicide rates in the United States.

METHODS

This state-level analysis used data from 2012 to 2016. The outcome variables were age-adjusted suicide and homicide rates. The predictor variables were NP scope of practice by state (limited, partial, or full) and RN ease of practice (state RN licensure compact membership status). Covariates were state sociodemographic, healthcare, and firearm/firearm policy context variables that have a known relationship with the outcomes.

RESULTS

Full scope of practice for NPs was associated with lower rates of suicide and homicide, with stronger associations for suicide. Likewise, greater ease of practice for RNs was associated with lower suicide and homicide rates.

CONCLUSIONS

Findings suggest that nurses are an important component of the healthcare ecosystem as it relates to injury outcomes. Laws supporting full nursing practice may have a protective effect on population health in the area of injuries and future studies should explore this relationship further.

Nurse practitioner's independent prescriptive authority and opioids abuse

This paper investigates the impact of legislative changes allowing nurse practitioners to prescribe schedule II controlled substances independently. We find that this legal environment is associated with an increase in treatment admissions for opioid misuse and a decrease in opioid related mortality only when Mandatory Prescription Drugs Monitoring Programs are in place.