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O'Reilly-Jacob M, Perloff J, Srinivasan M, Alvarez M, Hoyt A. State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis. J Gerontol Nurs 2023; 49:11-17. [PMID: 37126015 DOI: 10.3928/00989134-20230414-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.].
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Nikpour J, Franklin M, Calhoun N, Broome M. Influence of provider type on chronic pain prescribing patterns A systematic review. J Am Assoc Nurse Pract 2022; 34:474-488. [PMID: 34935726 PMCID: PMC9562618 DOI: 10.1097/jxx.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Durham, North Carolina
| | | | - Nicole Calhoun
- Duke University School of Nursing, Durham, North Carolina
| | - Marion Broome
- Ruby F. Wilson Professor of Nursing, Duke University School of Nursing, Durham, North Carolina
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Abstract
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.
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Romman AN, Hsu CM, Chou LN, Kuo YF, Przkora R, Gupta RK, Lozada MJ. Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers. PAIN MEDICINE 2021; 21:1400-1407. [PMID: 31904839 DOI: 10.1093/pm/pnz344] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Adam N Romman
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Connie M Hsu
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lin-Na Chou
- Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Rene Przkora
- Department of Anesthesiology, University of Florida, Gainesville, Florida
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M James Lozada
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Nikpour J, Broome M, Silva S. Assessing Practice Patterns and Influential Factors for Nurse Practitioners Who Manage Chronic Pain. Pain Manag Nurs 2021; 22:312-318. [PMID: 33714701 DOI: 10.1016/j.pmn.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - Susan Silva
- Duke University School of Nursing, Durham, NC
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Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care. J Gen Intern Med 2021; 36:478-486. [PMID: 32583346 PMCID: PMC7878646 DOI: 10.1007/s11606-020-05963-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 06/05/2020] [Indexed: 12/18/2022]
Abstract
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.
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Van Cleave JH, Booker SQ, Powell-Roach K, Liang E, Kawi J. A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse. Pain Manag Nurs 2021; 22:58-68. [PMID: 33414010 DOI: 10.1016/j.pmn.2020.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
| | - Staja Q Booker
- University of Florida, College of Nursing, Gainesville, Florida
| | | | - Eva Liang
- NYU Rory Meyers College of Nursing, New York, New York
| | - Jennifer Kawi
- University of Nevada, Las Vegas, School of Nursing, Las Vegas, Nevada
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Impact of Nurse Practitioner Scope of Practice on Treatment for Chronic Pain and Opioid Use Disorder: A Scoping Review. JOURNAL OF NURSING REGULATION 2021. [DOI: 10.1016/s2155-8256(20)30176-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J Gen Intern Med 2020; 35:2584-2592. [PMID: 32333312 PMCID: PMC7459076 DOI: 10.1007/s11606-020-05823-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 03/26/2020] [Indexed: 01/11/2023]
Abstract
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.
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The relationship of nursing practice laws to suicide and homicide rates: a longitudinal analysis of US states from 2012 to 2016. BMC Health Serv Res 2020; 20:176. [PMID: 32143696 PMCID: PMC7059356 DOI: 10.1186/s12913-020-5025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/24/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Grecu AM, Spector LC. Nurse practitioner's independent prescriptive authority and opioids abuse. HEALTH ECONOMICS 2019; 28:1220-1225. [PMID: 31243861 DOI: 10.1002/hec.3922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 04/10/2019] [Accepted: 05/15/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Anca M Grecu
- Department of Economics and Legal Studies, Seton Hall University, South Orange, New Jersey
| | - Lee C Spector
- Department of Economics, Ball State University, Muncie, Indiana
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