NPs no more likely to prescribe inappropriately to older patients than PCPs

Key takeaways:

• The crude rate of inappropriate prescribing was 1.63 and 1.69 per 100 prescriptions for NPs and PCPs, respectively.
• Experts agreed that the focus should be on improving prescribing rates of all clinicians.

Nurse practitioners were no more likely than primary care physicians to prescribe inappropriately to older patients, a study published in the Annals of Internal Medicine showed.

According to Johnny Huynh, MA, a doctoral candidate at the University of California, Los Angeles, and colleagues, 32 states and the District of Columbia have passed legislation allowing nurse practitioners (NPs) to prescribe medications without physician supervision.

Opposition from medical organizations against these legislations “rests chiefly on the contention that expanding prescribing authority to nonphysician providers will have adverse effects on quality of care,” they wrote. “Does the safety or appropriateness of NP prescribing fall short?”

To answer this, the researchers calculated and compared inappropriate prescribing rates of 23,669 NPs and 50,060 PCPs who wrote prescriptions for 100 or more patients a year from 2013 to 2019. The patients were Medicare Part D beneficiaries aged 65 years or older.

Overall, the crude rate of inappropriate prescribing was:

• 1.63 per 100 prescriptions among NPs; and
• 1.69 per 100 prescriptions among PCPs.

The researchers said the odds of inappropriate prescribing “were virtually identical” between NPs and PCPs (OR = 0.99; 95% CI, 0.97-1.01).

However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing.

“For example, NPs accounted for 32.1% of the total study sample, but 51.8% of clinicians in the lowest decile of inappropriate prescribing and 48.8% of clinicians in the highest decile,” Huynh and colleagues wrote.

The researchers concluded that to improve patient access while maintaining quality and safety, the question should not be whether NPs and other providers besides physicians should be able to prescribe but how prescribing can be improved among all clinicians.

“Use of clinician-level performance measures, coupled with efforts to improve prescribing at the organizational and individual levels, are one approach for achieving this,” they wrote.

In a related editorial, Michelle S. Keller, PhD, MPH, an adjunct assistant professor at the UCLA Fielding School of Public Health, and Catherine A. Sarkisian, MD, MSHS, a professor in residence at the UCLA David Geffen School of Medicine, shared similar sentiments, suggesting that the research not only highlights unacceptable rates of inappropriate prescribing “but also substantial variation in potentially inappropriate prescribing among clinicians of all stripes.”

“Nurse practitioners will continue to serve critical roles in ensuring that older adults in areas with inadequate numbers of health care providers receive primary care,” they wrote. “Our goal should be to reduce variation and improve prescribing quality among all clinicians who care for older adults.”

References:

• Huynh J, et al. Ann Intern Med. 2023;doi:10.7326/M23-0827.
• Keller M, Sarkisian C. Ann Intern Med. 2023;doi:10.7326/M23-2556.