The False Paradigm of Equivalency: Conceptual Challenges to Collaborative Care

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Every spring, I teach a graduate nursing class on physical assessment, which includes examining the evidence for the use of techniques such as jugular venous distention as diagnostic instruments. I caution my students that the accuracy of any technique depends fundamentally on what it is that you are trying to measure. In reflecting on collaborative practice in cardiology, I was reminded of the importance of conceptual clarity. Every nurse practitioner who has ever tried to explain their professional role only to be asked “why didn't you just become a physician?” knows on a practical level the conceptual challenge of collaborative care—defining the unique value of each profession, as well as their collaborative value.
The nurse practitioner role was initially introduced to alleviate the gap in primary care, which existed because of a healthcare system without adequate numbers of primary care physician providers, particularly in rural areas. The aging of the US population coupled with the rise of cardiovascular disease has created a similar gap in cardiovascular care—and again, nurse practitioners have moved to fill the gap. In the latest survey of nurse practitioner practice areas, cardiology was one of the leading specialties in which nurse practitioners practice—among all nurse practitioners, approximately 8.3% practice in cardiology, and among those certified in acute care, 21% practice in cardiology.1 The rapid growth in the numbers of both nurse practitioners and physician assistants led the American College of Cardiology to formally acknowledge the existence of nonphysician providers in 2015.2
The role of the nurse practitioner, initially intended to focus on health promotion among healthy children and women, has evolved considerably, with nurse practitioners now practicing in intensive care units and cardiac procedure units and, in some cases, running urgent care centers staffed only by nurse practitioners. This has increasingly led to nurse practitioners being viewed as cheaper physicians, the healthcare provider generic equivalent of a brand-name drug.
Establishing the equivalency of nurse practitioner practice to physician practice has been a focus of most studies on collaborative practice, including in cardiology.3 One of the largest, undertaken by Virani and colleagues,4 examined the quality measure compliance for outpatient coronary artery disease, heart failure, and atrial fibrillation using the American College of Cardiology's PINNACLE registry and demonstrated that there was no meaningful difference in the care delivered by nonphysician providers (nurse practitioners and physician assistants) than physicians. Such evidence has been used in political debates over State Board regulation of the degree of physician supervision required for nurse practitioner practice, a persistent thorn in the side of nurse practitioner practice. There has been a consistent movement toward independent practice, or at least fewer supervisory requirements, for nurse practitioners. The Department of Veteran Affairs made headlines earlier this year for granting independent practice to most advanced practice nurses (the exception being nurse anesthetists).5 The consistent message has been that nurse practitioners provide equal care for a cheaper price.
In the report generated by the Department of Veterans Affairs before the policy change, the authors noted that there are still gaps in the evidence on the equivalency of nurse practitioners with physicians.3 Most studies to date have been conducted in primary care and urgent care, and few have examined patient outcomes, particularly long term. In response to the Virani et al study, an editorial by Harrington and Heidenreich2 made a similar call for the long-term evaluation of patient outcomes in relation to provider type, more thorough economic analyses of collaborative care, and broader access to more complete data through better electronic data sharing.
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