Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States

Jiao, Shiyin; Murimi, Irene B.; Stafford, Randall S.; Mojtabai, Ramin; Alexander, G. Caleb

doi:10.1002/phar.2095

Cited by 43 publications

(38 citation statements)

References 31 publications

(30 reference statements)

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“…In terms of inappropriate prescribing practices, this study found that mid-level practitioners had a higher proportion of inappropriate antibiotic prescriptions compared to physicians. This is consistent with a study, 13 which compared prescribing patterns between physicians and mid-level practitioners (nurse practitioners and physician assistants). The study showed no significant differences in inappropriate prescribing in upper respiratory tract infections (odds ratio [OR] 0.75, 95% CI 0.50-1.14); however, they did note more appropriate prescribing practices with acute otitis media among physicians compared to mid-level practitioners (OR 0.41, 95% CI 0.24-0.70) and particularly to that of physician assistants (OR 0.21, 95% CI 0.06-0.75).…”

Section: Discussionsupporting

confidence: 91%

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

et al. 2020

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BACKGROUND Prior studies have found that outpatient antibiotics are commonly prescribed for nonbacterial conditions. It is unclear if national prescribing has changed in recent years given recent public health and antimicrobial stewardship initiatives. This study aimed to describe antibiotic prescribing in United States (U.S.) physician offices. MATERIALS/METHODS This was a cross-sectional study of all sampled patient visits in the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was defined as at least one oral antibiotic prescription during the visit as identified by Multum code(s). Patient visits were categorized by U.S. geographic region and season. ICD-9-CM and ICD-10 codes were used to assess diagnoses and categorize antibiotic use as appropriate, possibly appropriate, or inappropriate. RESULTS Seven billion visits were included for analysis, with 793,415,182 (11.3%) including an antibiotic. Prescribing rates were relatively stable over the study period (102.9-124.9 prescriptions per 1000 visits); however, 2016 had one of the lowest prescribing rates (107.7 per 1000 visits). The most commonly prescribed antibiotic class was macrolides (25 per 1000 visits). The South region and winter season had the highest antibiotic prescribing (118.2 and 129.7 per 1000 visits, respectively). Of patients who received an antibiotic, 55.9%, 35.7%, and 8.4% were classified as inappropriate, possibly appropriate, and appropriate, respectively. The most common conditions in which antibiotics were prescribed inappropriately included those with no indication in any of the predefined diagnosis codes (40.1%), other skin conditions (17.3%), and viral upper respiratory conditions (13.3%). CONCLUSIONS There was no significant reduction in outpatient antibiotic prescribing rates among U.S. outpatients from 2009 to 2016 and prescribing varied by region and season. These data suggest that more than half of antibiotics were prescribed inappropriately, with the majority of antibiotics prescribed with no indication. However, these findings need to be confirmed with robust prospective studies.

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Section: Discussionsupporting

confidence: 91%

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

et al. 2020

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“…This is not unexpected, as our study incorporated all practice types, was restricted to patients 65 years of age and older and only captured prescription encounters. Similar to our findings, studies in the United States found that patients cared for by NPs were slightly more likely to be female [45][46][47][48] and to reside in rural or underserviced areas. 25,[45][46][47][48] Contrary to the findings of studies in Ontario community health centres 30 and the US 46 that reported that higher proportions of patients of all ages cared for by NPs were marginalized than those cared for by family physicians, we did not find variation in the marginalization index of older adults across provider groups.…”

Section: Discussionsupporting

confidence: 90%

A population profile of older adults with prescription encounters with nurse practitioners and family physicians in Ontario: a descriptive retrospective cohort study

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Tranmer

Wei

et al. 2019

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Background: Compared with patients in family physician practices, there is a poor understanding at a population level of patients in nurse practitioner practices. The study aim was to use Ontario administrative databases to identify the sociodemographic characteris tics and comorbidities of patients aged 65 years and older who were prescribed medications by nurse practitioners and family phys icians between 2000 and 2015. Methods: This populationbased descriptive retrospective cohort study included patients 65 years of age and older with Ontario Health Insurance Plan eligibility and at least 1 prescription encounter with a nurse practitioner or family physician during the study period. Prescription identification of patients permitted their characterization by age, sex, geographical location, rurality, neighbour hood income and comorbidities. Patients were categorized into 3 provider groups on the basis of the percentage of prescription encounters with nurse practitioners versus family physicians. Results: In 2015, patients in the study cohort with prescriptions by nurse practitioners (n = 25 220) were younger than those with prescriptions by family physicians (40.3% were aged 65-69 yr) and they were more likely to be residents of lowincome neighbour hoods (44.0% were in the lowest 2 neighbourhood income quintiles) and to be living outside of central Ontario. In contrast, patients who received prescriptions from family physicians (n = 1 952 904) tended to be older (26.8% were aged ≥ 80 yr), to have higher incomes (21.1% were in the highest neighbourhood income quintile) and to live in urban areas (86.5%). Mean Elixhauser Comorbid ity Index scores were consistently lower among patients cared for by nurse practitioners than among those predominantly seen by family physicians (1.30 v. 2.04). The most prevalent conditions were hypertension and diabetes, regardless of provider. Interpretation: The patient characteristic with the highest variability between providers was geographic residence in the province. Elucidating patterns of care is critical for primary care policy and our results provide baseline data for future health care planning.

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“…Previous literature has examined prescribing practices between NPs and physicians on common medications. In general, prescribing patterns and quality were comparable between NPs and physicians [38]. Some studies found that NP prescription practices were different from physicians in rural areas and with regard to the prescription of opioid medication [39,40].…”

Section: Discussionmentioning

confidence: 94%

Understanding the role of nurse practitioners, physician assistants and other nursing staff in HIV pre-exposure prophylaxis care in the United States: a systematic review and meta-analysis

et al. 2020

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Background Although pre-exposure prophylaxis (PrEP) was approved for primary HIV prevention by the Federal Drug Administration in 2012, PrEP utilization has been suboptimal. A body of literature and programs has emerged to examine the role of nurse practitioners (NPs), physician assistants and nursing staff in PrEP care. This review aims to understand the current status of non-physician health providers in PrEP care implementation in the United States. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance, we conducted a comprehensive literature search using multiple databases to identify peer-reviewed articles that examined the role of non-physician health providers in the implementation of PrEP. Four major databases of studies using observational study design, randomized control trials and mixed-method study design were screened from November 2019 to January 2020 were searched. Two independent reviewers examined eligibility and conducted data extraction. We employed random-effects model aims to capture variances of estimates across studies. Results A total of 26 studies with 15,789 health professionals, including NPs (18, 95% CI = 14,24%), physician assistants (6, 95% CI = 2, 10%), nursing staff (26, 95% CI = 18–34%), and physicians (62,95% CI = 45, 75%), were included in the analysis. The odds of prescribing PrEP to patients among NPs were 40% (OR = 1.40, 95% CI = 1.02,1.92) higher than that among physicians, while the likelihood of being willing to prescribe PrEP was similar. On the other hand, the odds of being aware of PrEP (OR = 0.63, 95% CI = 0.46, 0.87) was 37% less in nursing professionals than that among physicians. Conclusions Although the limited number and scope of existing studies constrained the generalizability of our findings, the pattern of PrEP care implementation among non-physician health providers was described. To achieve wider PrEP care implementation in the U.S., increasing awareness of PrEP among all health providers including both physicians and non-physicians is a key step.

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Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States

Abstract: Although significant shortfalls exist in the quality of ambulatory prescribing across all practitioner types, the quality of care delivered by nonphysicians and physicians was generally comparable.

Cited by 43 publications

References 31 publications

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

A population profile of older adults with prescription encounters with nurse practitioners and family physicians in Ontario: a descriptive retrospective cohort study

Understanding the role of nurse practitioners, physician assistants and other nursing staff in HIV pre-exposure prophylaxis care in the United States: a systematic review and meta-analysis

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