Elsevier

Preventive Medicine

Volume 40, Issue 6, June 2005, Pages 718-724
Preventive Medicine

Context of care or provider training: the impact on preventive screening practices

https://doi.org/10.1016/j.ypmed.2004.09.013Get rights and content

Abstract

Background

While MD adherence to U.S. Preventive Services Task Force guidelines has been found to be uneven, nurse practitioners (NPs) and their adherence to guidelines have not been closely examined.

Methods

A retrospective chart review of new patients (n = 1339) in an NP primary health care center, four MD primary health care centers, and one private NP practice. Screening and counseling were compared for NPs and MDs.

Results

When patient populations, resources, and administrative policies were similar in the NP and MD primary health care centers, NPs were more likely than MDs to perform primary prevention; however, MDs were more likely to document the delivery of secondary prevention screening. Private practice NPs' performance was more congruent with practice guidelines than either NP or MD primary health care center providers. Private practice NPs were more likely to perform screening, assessment, and counseling.

Conclusions

When context, patient population, and productivity requirements were the same, NPs and MDs differed in their use of preventive measures, and not as expected. When NPs are not constrained by productivity requirements, and when their patient population has more resources and higher expectations, NPs perform better than their primary care center counterparts, particularly in secondary prevention and assessment and counseling.

Introduction

It is estimated that half of all deaths in the United States are premature [1]. Primary health care providers can play an important role in reducing these early deaths through the delivery of periodic preventive health care screening and counseling. While physician adherence to U.S. Preventive Services Task Force (USPSTF) guidelines has been found to be uneven [2], [3], [4], [5], [6], nurse practitioners and their adherence to guidelines have not been as closely examined.

Several studies to date have compared nurse practitioners with physicians in the provision of primary care, using several measures such as USPSTF guidelines. Outcomes of patients cared for by nurse practitioners (NPs) have been found to be comparable to MD care [7], [8], [9] and the costs associated with NP care have been demonstrated to be lower [10]. Although much of the attention in comparative studies has focused on patient outcomes, there is a growing body of evidence that NPs and MDs also differ in the preventive and treatment strategies they employ during patient encounters and in the populations served. For example, the process of NP and MD patient encounters and the populations these providers tend to serve have been examined in several studies using data from the National Ambulatory Medical Care Survey (NAMCS). Hooker and McCaig [11] found that NPs directly supervised by MDs saw younger patients than MDs and provided counseling and education during a higher proportion of visits [11]. Aparasu and Hegge [12] examined patient encounters of NPs combined with physicians' assistants (PAs) and found that NP/PA patients were more likely to be 65 years or older, female, Black, and from the Northeastern United States, when compared to MD patients [12]. They also found NP/PAs to have more visits for “nonillness care” and more emphasis on therapeutic/preventive care. Moody et al. [13] also used NAMCS data and found NPs to have younger client who were more often female [13]. NPs also tended to provide more health counseling interventions and, not surprisingly, to perform fewer office surgical procedures. Lin et al. [14] used NAMCS data to compare NP to PA practice and found that NPs saw a larger proportion of visits, provided more preventive and therapeutic services, and played a larger role in OB/GYN clinics than PAs [14].

Studies employing other techniques, such as chart review and vignettes, have also revealed differences between MDs and NPs in the practice characteristics carried out during patient encounters. In a chart review study comparing NPs and MDs in the primary care of adults with type 2 diabetes, NPs were found to be more likely than MDs to document the provision of general diabetes education and education about nutrition, weight, exercise, and medications [15]. NPs were also more likely to document patient height, urinalysis results, and A1c values. A national study using case vignettes [16] found NPs to be more thorough in medical history taking than MDs. General preventive screening of patients has been examined recently through chart review [17]. Pieper and Dinardo [17] conducted a review of 10 health maintenance items and found relatively poor overall compliance with rectal examinations, pneumococcal vaccinations, and fecal occult blood tests [17]. Better performance was seen for cholesterol screening and mammography. Patients in this study who were followed by NPs experienced better rates of adherence to prevention measures than patients followed by NP-MD teams, or MDs alone, although all groups had relatively low adherence to prevention guidelines. Inconsistent adherence to diabetes guidelines has been found for NPs studied in isolation [18], as well as MDs [19].

NPs and MDs are assumed to behave differently in part because their basic professional educations differ; they are socialized differently through varying approaches to health and the provider role [20]. Through their undergraduate training, nurses are socialized within a model that stresses health promotion and disease prevention, with emphasis on the individual within a family and community context, while MDs are more oriented toward differential diagnosis and treatment of specific illnesses and a biological model of illness. Based on these differences in basic professional education, one can predict that NPs are more likely to provide patient education and counseling during an office visit, and that MDs are more likely to focus on illness, screening, monitoring, and treatment. Differences in NP and MD behaviors may also be influenced by the different patient populations, with NPs being more likely to care for patients who are healthier or are chronically, rather than acutely, ill. These differences could theoretically influence the manner in which NPs and MDs deliver care.

Although undergraduate nursing and medical education have traditionally differed, they are becoming more alike. Medical education has expanded its curriculum to embrace the “humanistic model” of health care [21]. Medical school deans have also reported an interest in increasing competencies in health promotion and disease prevention in the curriculum [22], which might cause medical education to more closely resemble nursing education's emphasis on counseling and teaching [23]. Similarly, graduate training for NPs draws heavily from the medical model. Both nursing and medicine are exposed to the same established preventive and screening guidelines for primary care. If both fields are similarly trained and exposed to recommended preventive behavior, it would seem likely that some of their practice styles would be similar.

The various contexts in which care is delivered may be as important in predicting provider behaviors as the provider's background training or orientation. The community and demographic practice environment may be important. For example, levels of patient education and income have been shown to positively affect the likelihood of having a mammogram, Pap smear, and cholesterol screening [24], and income alone has been demonstrated to affect the likelihood of receiving counseling about risk behaviors [25]. Patient age and chronic disease status have been shown to predict cancer screening [26], [27], [28]. Insurance status has been shown to impact mammogram rates [28], [29], as well as Pap tests, sigmoidoscopies, and fecal occult blood tests [28]. In addition to these variables, the setting for the care delivery has been found to be important. For example, regional differences in treatment patterns are common [30], [31], [32], even in the national VA health care system [33]. The organizational context also influences practice patterns. Practices may differ because of differences in resources and productivity requirements, in the formal protocols that are in place and in the informal norms that emerge within an organization [34].

To explore the impact of provider training and the context of care impact on the receipt of preventive services, this study examines data from two samples of primary care encounters: (1) a chart review of patients assigned randomly to an independent NP primary care center or an MD center; and (2) a parallel chart review of patients seen in a separate independent NP practice. By comparing encounters with patients from primary care practices that are organizationally and demographically similar but use two different types of providers, we were able to examine potential differences in NP and MD primary care delivery patterns. By comparing two NP practices that differ organizationally (private office-setting practice versus an ambulatory primary care center located in a hospital's clinic network) but employ the same type of provider, we were able to examine how a different patient population and context may influence the process of care employed by NPs.

Section snippets

Methods

A retrospective chart review of new patients cared for in three different types of practices within an academic health center was conducted. The practice types included a primary health care center staffed only by nurse practitioners, four primary health care centers staffed by physicians, and a private practice staffed only by nurse practitioners. The recorded information about the first patient encounter between patient and provider and any encounters during the subsequent 6 weeks was

Study population

Primary health care center patients (n = 755 NP patients and n = 441 MD patients) were on average 46 years old (SD 14.93), female (76.8%), Hispanic (90.4%), and enrolled in Medicaid (88.3%). Patients in the private NP practice (n = 143) were on average 38.7 years old (SD 16.6), female (79%), White (74.1%), and enrolled in a private health insurance plan that accepts an NP as an independent provider (69.2%). Additional demographic information regarding employment, educational, and marital status

Data analysis

Using chi-square analysis, the percentage of patients who received preventive screening and counseling behaviors during the first 6 weeks of encounters with the primary care provider were compared across the three subgroups: the NP primary health care center patients, the MD center patients, and the NP private practice patients. We compared proportions of patients for whom history and physical and assessment and counseling were documented, as well as the percentage of patients for whom primary

Primary health care center NPs compared to primary health care center MDs

When comparing center NPs to center MDs, where patient populations were very similar, results indicated that NPs were significantly more likely than MDs to document last menstrual period and height (P < 0.0001) and current medications (P < 0.05), while MDs were more likely to document weight (P <0.05). NPs were more likely than MDs to perform primary prevention (cholesterol, TB, tetanus, hepatitis B, and syphilis screening); however, MDs were more likely to document screening for HIV (P <

Discussion

When context, patient population, and productivity requirements were the same, NPs and MDs differ in their use of preventive measures, and not consistently in expected ways. When NPs are not constrained by productivity requirements, when their patient population has more resources and higher expectations, NPs perform better than their primary care center colleagues, particularly in secondary prevention and assessment and counseling. The results provide insight into potential differences between

Acknowledgments

The authors gratefully acknowledge Annette M. Totten, MPA, for her contributions to the data collection for this article. Funding for this study was received from the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation.

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