Study: ED Docs Offer Better Care Than Nurse Practitioners


By Frank Diamond

Nurse practitioners deliver care in emergency departments that produces worse outcomes at higher costs, according to a working paper by the National Bureau of Economic Research (NBER).

Researchers at Stanford University found that care by NPs increases lengths of stay in hospitals by 11% and accounts for 20% more preventable hospitalizations compared to emergency department doctors.

The working paper concludes that “equal productivity between NPs and physicians would imply that the process to become a physician is unnecessarily selective, that the additional years of training is wasteful from society’s perspective, and that the two-fold higher salary of physicians reflects monopoly rents and perhaps institutions based on the mistaken concept that physicians are worth the higher price of their labor.”

The paper’s conclusion, however, indicates that physicians should indeed be paid more for their labor compared to NPs.

Perhaps not surprisingly, April Kapu, begs to differ. She says that the working paper is "based on a very small sample size, in a single work setting and is not an accurate representation of NP practice or value. Each year, NPs across the nation deliver high-quality healthcare in more than 1 billion patient visits. Meeting the nation’s healthcare needs requires all of us," Kapu said.

It takes between 10,000 and 16,000 hours of medical education to become a physician, compared to the 500 to 720 hours that it takes to become an NP, which usually occurs in graduate school. Researchers with NBER, a not-for-profit economic research organization, analyzed Veterans Health Administration (VHA) data from 2017 to 2020, right before the onslaught of the COVID-19 pandemic. The paper notes that in December 2016, the VHA instituted a policy that gives NPs full practice authority; they could offer the same care that physicians offer at VHA emergency rooms.

The result was longer hospital stays and more preventable hospitalizations under NP care that led to an increase in the costs of ED care by 7%, or $66 per patient, according to the researchers.

Experience matters, the research argues, and the “NP-physician gap in resource utilization narrows among providers who have seen more prior patients, both in general and for the diagnosis in question. This suggests that differences in training may play some role in the productivity differences between NPs and physicians.”

However, the paper states that the lower skillset among NPs led them to gather information (increasing cost) from outside sources through, for instance, radiology tests and consultations with other providers.

The paper states that “NPs are less likely to prescribe opioids, which have higher health risks if incorrectly prescribed, but they are more likely to prescribe antibiotics, which have higher health risks if incorrectly not prescribed.”

The working paper also states that NPs often make the wrong decisions concerning which patients to admit, “resulting in under-admission of patients who should have been admitted and a net increase in return hospitalizations, despite NPs using longer lengths of stay to evaluate patients’ need for hospital admission; NPs produce lower quality of care conditional on admitting decisions, despite spending more resources on treating the patient (as measured by costs of the ED care). Both possibilities imply lower skill of NPs relative to physicians.”

The working paper cites a study conducted by researchers with Johns Hopkins University, the University of New Mexico, the Department of the Army and other institutions that states: “Extensive variability exists across the academic preparation of NPs working in the ED setting as well as in the licensure and certification requirements governing NP practice in EDs. Until this variability is resolved, we conclude that NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety.”

Kapu, though, is holding her ground, insisting on the importance and competency of NPs in healthcare, and she cites research that supports that position.

“For decades, nurse practitioners have been providing high-quality care to patients across the life span in nearly every healthcare setting,” she says. “NP care is safe and cost-effective with studies finding significant savings for patients with complex and chronic conditions. As the healthcare industry faces unprecedented workforce shortages and increasing healthcare needs, NPs are and will continue to be vitally important to patient’s access to high-quality healthcare.”


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