It's as safe to get your prescription from a nurse practitioner as from a doctor
Nurse practitioners are just as good as primary care doctors at avoiding potentially harmful prescriptions for older patients—but both need to do better, a large, new study suggests.
Nurse practitioners (NPs) are registered nurses with advanced training in doing many of the same things doctors do, including diagnosing diseases and devising treatment plans. As the United States continues to face a shortage of primary care doctors, NPs have been critical to filling that gap.
One sticking point has been prescribing medications. Many U.S. states allow NPs full prescribing authority, while some limit the kinds of drugs they can prescribe or require them to be overseen by a doctor.
Opposition to NP prescribing generally falls along the lines of patient safety—that is, they're not as good at it as doctors are.
But the new study, published Oct. 23 in the Annals of Internal Medicine, shows otherwise.
Across 29 U.S. states, researchers found NPs and primary care doctors were right on par when it came to rates of potentially "inappropriate" prescriptions to older adults. On average, those questionable prescriptions made up about 1.7% of all prescriptions in both groups.
The positive interpretation is that seniors who see an NP have no reason to worry that their care will be inferior, said senior researcher David Studdert, a professor of health policy and law at Stanford University.
On the other hand, he said, there was wide variation from one NP to another, and from one doctor to another: In both groups, some providers made questionable prescriptions at a relatively high rate, while others rarely did.
In other words, there's room for improvement among NPs and doctors alike, said Studdert.
And that, he said, is probably where the focus should be—rather than debating whether NPs should be allowed to prescribe at all.
Dr. Catherine Sarkisian, a professor and geriatrician at the University of California, Los Angeles, agreed.
Given the national shortage of primary care doctors, NPs are a critical source of care for many Americans, said Sarkisian, who co-authored an editorial published with the study.
What's important, she said, is addressing the variance in prescribing "across disciplines": Why do some providers account for a disproportionate share of potentially inappropriate prescriptions?
There are numerous potential reasons, Sarkisian said. Some providers may be unaware of guidelines recommending against certain medications for elderly people. Others may disagree with the guidelines, at least for some of their patients.
And sometimes, Sarkisian said, patients ask for a medication and the provider relents.
What makes a prescription potentially inappropriate?
In their study, Studdert and his colleagues defined that according to criteria laid out by the American Geriatrics Society. In a nutshell, they are prescriptions that, for elderly adults, may do more harm than good.
Examples include opioid painkillers; benzodiazepines (Valium and Xanax), which can impair thinking and memory and increase the risk of falls; heartburn medications known as proton pump inhibitors (Prilosec and Nexium), where long-term use has been tied to bone fractures, nutrient deficiencies and other health risks.
It's not that older adults should never use those medications, Studdert pointed out.
"But," he said, "in most cases, they should not be prescribed."
The findings are based on Medicare data linked to over 23,000 NPs and 50,000 primary care doctors in 29 states where, as of 2019, NPs had prescribing authority.
Between 2013 and 2019, the average rate of potentially inappropriate prescribing by NPs and doctors was nearly identical.
But individual providers varied widely in their practices, the study found—with NPs varying more so than doctors. Although NPs made up about one-third of the study group, they accounted for almost half of providers in the top 10% for inappropriate prescribing.
That does not, however, mean they offered inferior care, both Studdert and Sarkisian noted: NPs also accounted for half of providers in the 10% with the lowest rates of inappropriate prescribing.
For seniors, the findings underscore the importance of speaking up.
"They should feel empowered to ask questions," Sarkisian said. "Ask why you're taking a medication. Ask about side effects. Ask, what happens if I don't take this medication?"
And for some medications, Sarkisian noted, there's comes a time when it's best to "de-prescribe." As people age, the side effects of a medication they've taken for years may start to outweigh the potential benefits.
More information: Johnny Huynh et al, Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians, Annals of Internal Medicine (2023). DOI: 10.7326/M23-0827
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