New chronic disease medication prescribing by nurse practitioners, physician assistants, and primary care physicians: a cohort study

Abstract

BackgroundMedications to treat and prevent chronic disease have substantially reduced morbidity and mortality; however, their diffusion has been uneven. Little is known about prescribing of chronic disease medications by nurse practitioners (NPs) and physician assistants (PAs), despite their increasingly important role as primary care providers. Thus, we sought to conduct an exploratory analysis to examine prescribing of new chronic disease medications by NPs and PAs compared to primary care physicians (PCPs).MethodsWe obtained prescribing data from IMS Health’s Xponent™ on all NPs, PAs, and PCPs in Pennsylvania regularly prescribing anticoagulants, antihypertensives, oral hypoglycemics, and/or HMG-Co-A reductase inhibitors pre- and post-introduction of five new drugs in these classes that varied in novelty (i.e., dabigatran, aliskiren, sitagliptin or saxagliptin, and pitavastatin). We constructed three measures of prescriber adoption during the 15-month post-FDA approval period: 1) any prescription of the medication, 2) proportion of prescriptions in the class for the medication, and 3) time to adoption (first prescription) of the medication.ResultsFrom 2007 to 2011, the proportion of antihypertensive prescriptions prescribed by NPs and PAs approximately doubled from 2.0 to 4.2 % and 2.2 to 4.9 %, respectively. Similar trends were found for anticoagulants, oral hypoglycemics, and HMG-Co-A reductase inhibitors. By 2011, more PCPs had prescribed each of the newly approved medications than NPs and PAs (e.g., 44.3 % vs. 18.5 % vs. 20 % for dabigatran among PCPs, NPs, and PAs). Across all medication classes, the newly approved drugs accounted for a larger share of prescriptions in the class for PCPs followed by PAs, followed by NPs (e.g., dabigatran: 4.9 % vs. 3.2 % vs. 2.8 %, respectively). Mean time-to-adoption for the newly approved medications was shorter for PCPs compared to NPs and PAs (e.g., dabigatran, 7.3 vs. 8.2 vs. 8.5 months; P all medications <0.001).ConclusionsPCPs were more likely to prescribe each of the newly approved medications per each measure of drug adoption, regardless of drug novelty. Differences in the rate and speed of drug adoption between PCPs, NPs, and PAs may have important implications for care and overall costs at the population level as NPs and PAs continue taking on a larger role in prescribing.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1569-1) contains supplementary material, which is available to authorized users.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

“…"It was expected that the nurse practitioner would help most with straightforward cases, freeing physicians to address complex care situations when they returned to the office, but the nurse practitioner instead took an enhanced role in the management of the most-complex patients on the Team Approach physician panels." [46,47], US "Our findings are consistent in that PCPs were more likely than NPs and PAs to prescribe to older patients, who often take multiple medications due to chronic co-morbidity. Given an older, more complex patient panel, PCPs may be more likely to prescribe from a broader prescription armamentarium, including newly approved drugs.…”

“…When observing prescription patterns of GPs caring for chronically ill patients, it seems they care for more complex cases, because they prescribe more and newer medications compared to NPs. This assumption is derived from the fact that co-morbid patients require more medication [47]. This is in keeping with the concept of previous surrogate terms for complexity being comorbidity or multimorbidity [15].…”

“…As can be seen in Table 3 [24,57], five from the Netherlands [26,27,49,54,56], one from Norway and Finland [28], five from Canada [29,30,36,41,59] and one from the UK [60]. Eight studies are qualitative in design [23][24][25][26][27][28][29][30] and twenty-one are quantitative [31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][47][48][49][50][51][52]. Additionally, there are four studies in which mixed methods are applied [53,54,59,60], one review [55], one country comparison…”

“…Patient populations are either specific or unspecific. Twelve studies included specific patient populations, two of which were older adults [27,28], seven diabetics [31,33,39,40,43,51,52], two chronically ill [47,48], and one home-bound [45], whereas twenty-five studies included unspecific patient populations consisting of general primary care patients.…”

“…In teams consisting of only two health professionals NPs may treat less complex patients [23,24,29,39,43,47,49,[53][54][55] or more socially complex patients [40,41]. This may lead to increased patient access to primary care [54], increased time for GPs to treat (medically) complex cases [34,35,44,[53][54][55], reduced referrals to specialists [35], and increased patient outcomes [31].…”