Delaware County Medical Society Winter 2017 - 17

a master's degree which could take two to three years based
on whether the education is full or part time. However, there
are accelerated programs, many online, that could grant a
primary care advanced practice in nursing master's degree in
as little as sixteen months. Six to seven years, however, could
be considered typical. Due to this discrepancy in education
requirements between the two, I think it is fair to state that
a common response from those individuals choosing a path
to nurse practitioner over a medical degree and residency
is that of "lifestyle." The years dedicated to education and
hours per day involved would be too burdensome along
with the expected continued long hours of clinical work
and education required to maintain skills and certification.
It is appropriate, in my opinion, to make such life choices
whichever path is decided upon. However, that dedication
of hours, days and years should be taken into consideration.
There are multiple studies, whether meta-analyses or
individual studies, touting care equivalency between nurse
practitioners and primary care physicians. Most studies,
however, were observational, utilizing surveys to determine
wellness and satisfaction with care. Furthermore, many
of the clinical endpoints such as blood pressure and
glucose control are commonly protocol-driven, and as
I describe below, may not be the appropriate indicators
for the need for a collaborative agreement. One of the
most cited studies, using the most commonly utilized
study design and endpoints, is from 2000 by Mary O.
Mundinger, Dean Emerita of the Columbia School
of Nursing, and colleagues entitled "Primary Care
Outcomes in Patients Treated by Nurse Practitioners or
Physicians: A Randomized Trial." Patients in an urban
environment were interviewed and physiologic test results
were examined at six months after initial evaluation, and
healthcare utilization data was recorded at six months
and one year. There was no significant difference in
health status and satisfaction based on the surveys and
no difference in glucose control or healthcare utilization.
Diastolic blood pressures were lower under the care of
the nurse practitioners (82 mm Hg vs. 85 mm Hg).
What are possible limitations, however, of this study (and
many of the studies)? Again, much is based on survey
results. In this case, 90% of the population was only
Spanish-speaking and the results had to be then translated
into English with possible variability in translating the
responses. Healthcare utilization may be skewed due
to ethnic norms and access as well. The tests used to
determine outcome were narrowly focused on blood
pressure, glycosylated hemoglobin and peak flow rates
for asthmatics. 3397 patients were screened but only 1316
were included in the study. Lastly, New York is a state
that requires a collaborative agreement and there were no
obvious controls for utilizing the collaborating physician
in those patients cared for by the nurse practitioners.
What are the goals of a collaborative agreement? To allow

an extension of patient care utilizing mid-level providers,
but, still having a level of easily attainable physician
oversight, especially with more complex cases or those
patients with illnesses not easily diagnosable. That being
true, it is obvious why endpoints such as blood pressure or
glycosylated hemoglobin are not appropriate to compare
equality of care or the need for a collaborative agreement.
Furthermore, utilizing the collaborating physician could
and should decrease the need for physician specialist
consultation along with the added healthcare expense.
What are the drawbacks of a collaborative agreement?
Common complaints noted by nurse practitioners are
unavailability of collaborating physicians based on
geographic limitations or limitations on the number of
collaborative agreements that physicians can have, inability
to contact the collaborating physician, and that collaboration
in general limits healthcare. In Pennsylvania, however,
there are no geographical restrictions and there are no
defined limits on the number of collaborating agreements a
physician can have. Therefore, there should be no limitations
on healthcare delivery even in the far rural areas that are
in great need of primary care providers. Furthermore,
who is to say that a nurse practitioner will venture into
those out-of-the-way areas any more than physicians
since there is no requirement for them to do so? The
majority of nurse practitioners are actually found in urban
areas. As for not being able to contact the collaborating
physician; that can be rectified by the development of
a cohesive relationship between the nurse practitioner
and physician along with the placement of a successful
contact mechanism. Also in Pennsylvania, so as not to
limit healthcare delivery, meetings and case discussions
on "a regularly scheduled basis" are defined within each
collaborative agreement and not by regulation or law.
The Pennsylvania Medical Society has been asked
to negotiate and compromise in order to form an
agreement between the two parties by the Pennsylvania
Legislative leaders; however, any such "agreement"
based on the current requirements would have to be
the eventual independent practice after a prescribed
number of hours served with a collaborator.
Without enough (or any) well-performed studies assuring
that major acute illness leading to significant morbidity or
mortality is avoided equally between nurse practitioners
without a collaborative agreement and primary care
physicians, and without evidence that healthcare accessibility
is truly compromised due to the presence of a collaborative
agreement in Pennsylvania; removing the collaborative
agreement requirement for any reason or after any specified
time adds no benefit to patient care in our Commonwealth.
Reprinted from the PSA Sentinel, with permission

www.delcomedsoc.org

DELAWARE COUNTY MEDICINE & HEALTH

15


http://www.delcomedsoc.org

Table of Contents for the Digital Edition of Delaware County Medical Society Winter 2017

Delaware County Medical Society Winter 2017 - 1
Delaware County Medical Society Winter 2017 - 2
Delaware County Medical Society Winter 2017 - 3
Delaware County Medical Society Winter 2017 - 4
Delaware County Medical Society Winter 2017 - 5
Delaware County Medical Society Winter 2017 - 6
Delaware County Medical Society Winter 2017 - 7
Delaware County Medical Society Winter 2017 - 8
Delaware County Medical Society Winter 2017 - 9
Delaware County Medical Society Winter 2017 - 10
Delaware County Medical Society Winter 2017 - 11
Delaware County Medical Society Winter 2017 - 12
Delaware County Medical Society Winter 2017 - 13
Delaware County Medical Society Winter 2017 - 14
Delaware County Medical Society Winter 2017 - 15
Delaware County Medical Society Winter 2017 - 16
Delaware County Medical Society Winter 2017 - 17
Delaware County Medical Society Winter 2017 - 18
Delaware County Medical Society Winter 2017 - 19
Delaware County Medical Society Winter 2017 - 20
Delaware County Medical Society Winter 2017 - 21
Delaware County Medical Society Winter 2017 - 22
Delaware County Medical Society Winter 2017 - 23
Delaware County Medical Society Winter 2017 - 24
Delaware County Medical Society Winter 2017 - 25
Delaware County Medical Society Winter 2017 - 26
Delaware County Medical Society Winter 2017 - 27
Delaware County Medical Society Winter 2017 - 28
Delaware County Medical Society Winter 2017 - 29
Delaware County Medical Society Winter 2017 - 30
Delaware County Medical Society Winter 2017 - 31
Delaware County Medical Society Winter 2017 - 32
https://www.nxtbook.com/hoffmann/delcomed/DelawareMedicalSocietySummerFall2020
https://www.nxtbook.com/hoffmann/delcomed/DelawareMedicalSocietySpring2020
https://www.nxtbook.com/hoffmann/delcomed/DelawareMedicalSocietyFall2019
https://www.nxtbook.com/hoffmann/delcomed/LivingwithLossfromAddiction
https://www.nxtbook.com/hoffmann/delcomed/DelcoMedicalSocietySummer2019
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietySpring2019
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietyWinter2019
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietyFall2018
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietySummer2018
https://www.nxtbook.com/hoffmann/delcomed/DelcoMedicalSocietySpring2018
https://www.nxtbook.com/hoffmann/delcomed/DelcoMedicalSociety
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietyWinter2017
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietyFall2017
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSocietySpring2017A
https://www.nxtbook.com/hoffmann/delcomed/DelawareCountyMedicalSociety
https://www.nxtbookmedia.com