State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review

Abstract

There is a great variation across states in nurse practitioner (NP) scope of practice moderated by state regulations. The purpose of this study was to synthesize the evidence from studies of the impact of state NP practice regulations on U.S. health care delivery outcomes (e.g., health care workforce, access to care, utilization, care quality, or cost of care), guided by Donabedian’s structure, process, and outcomes framework. This systematic review was performed using Medline, CINAHL, PsycINFO, and PubMed according to Preferred Reporting Items for Systematic and Meta-Analysis on the literature from January 2000 to August 2019. The results indicate that expanded state NP practice regulations were associated with greater NP supply and improved access to care among rural and underserved populations without decreasing care quality. This evidence could provide guidance for policy makers in states with more restrictive NP practice regulations when they consider granting greater practice independence to NPs.

Keywords

practice regulations nurse practitioners access to care quality of care health care cost health care utilization and workforce

Get full access to this article

View all access options for this article.

References

Alexander

Schnell

(2019). Just what the nurse practitioner ordered: Independent prescriptive authority and population mental health. Journal of Health Economics, 66(1), 145-162. https://doi.org/10.1016/j.jhealeco.2019.04.004

American Academy of Nurse Practitioners. (2019). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment

Association of American Medical Colleges. (2019). New findings confirm predictions on physician shortage. https://news.aamc.org/press-releases/article/2019-workforce-projections-update/

Barnes

Maier

C. B.

Sarik

D. A.

Germack

H. D.

Aiken

L. H.

McHugh

M. D.

(2017). Effects of regulation and payment policies on nurse practitioners’ clinical practices. Medical Care Research and Review, 74(4), 431-451. https://doi.org/10.1177/1077558716649109

Barnes

Richards

M. R.

McHugh

M. D.

Martsolf

(2018). Rural and nonrural primary care physician practice increasingly rely on nurse practitioners. Health Affairs, 37(6), 908-914. https://doi.org/10.1377/hlthaff.2017.1158

Berwick

Fox

D. M.

(2016). Evaluating the quality of medical care: Donabedian’s class article 50 years later. Milbank Quarterly, 94(2), 237-241. https://doi.org/10.1111/1468-0009.12189

Carthon

J., M., B.

Sammarco

Pancir

Chittams

Nicely

K. W.

(2017). Growth in retail-based clinics after nurse practitioner scope of practice reform. Nursing Outlook, 65, 195-201. https://doi.org/10.1016/j.outlook.2016.11.001

Cassidy

(2012, October 25). Health policy brief: Nurse practitioners and primary care. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20121025.024639/full/

Chapman

S. A.

Wides

C. D.

Spetz

(2010). Payment regulations for advanced nurse practitioners: Implications for primary care. Policy, Politics, & Nursing Practice, 11(2), 89-98. https://doi.org/10.1177/1527154410382458

10.

Chicoine

Aselton

(2015). Nurse practitioner role in home healthcare: Challenges and opportunities. Clinical Nursing Studies, 3(1), 100-102. https://dx-doi-org.web.bisu.edu.cn/10.5430/cns.v3n1p100

11.

Dillon

Hoyson

P. M.

(2014). Beginning employment: A guide for the new nurse practitioner. Journal for Nurse Practitioners, 10(1), 55-59. https://doi.org/10.1016/j.nurpra.2013.09.009

12.

Donabedian

(1979). The quality of medical care: A concept in search of a definition. Journal of Family Practice, 9(2), 277-284.

13.

Donelan

DesRoches

C. M.

Dittus

R. S.

Buerhaus

(2013). Perspectives of physicians and nurse practitioners on primary care practice. New England Journal of Medicine, 368, 1898-1906. https://doi.org/10.1056/NEJMsa1212938

14.

Fauteux

Brand

Fink

J. L. W.

Frelick

Werrlien

(2017). The case for removing barriers to APRN practice. https://www.rwjf.org/en/library/research/2017/03/the-case-for-removing-barriers-to-aprn-practice.html

15.

Gadbois

E. A.

Miller

E. A.

Tyler

Intrator

(2015). Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010. Medical Care Research and Review, 72(2), 200-219. https://doi.org/10.1177/1077558714563763

16.

Gilman

D. J.

Koslov

T. I.

(2014). Policy perspectives: Competition and the regulation of advanced practice nurses. https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf

17.

Goodfellow

Ulloa

J. G.

Dowling

P. T.

Talamantes

Chheda

Bone

Moreno

(2016). Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine, 91(9), 1313-1321. https://doi.org/10.1097/ACM.0000000000001203

18.

Grant

Lines

Darbyshire

Parry

(2017). How do nurse practitioners work in primary health care settings? A scoping review. International Journal of Nursing Studies, 75(1), 51-57. https://doi.org/10.1016/j.ijnurstu.2017.06.011

19.

Graves

J. A.

Mishra

Dittus

R. S.

Parikh

Perloff

Buerhaus

P. I.

(2016). Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity. Medical Care, 54(1), 81-89. https://doi.org/10.1097/MLR.0000000000000454

20.

Grecu

A. M.

Spector

L. C.

(2019). Nurse practitioners’ independent prescriptive authority and opioids abuse. Health Economics, 28(10), 1220-1225. https://doi.org/10.1002/hec.3922

21.

Hain

Fleck

(2014). Barriers to nurse practitioner practice that impact healthcare redesign. Online Journal of Issues in Nursing, 19(2), Article e02. https://doi.org/10.3912/OJIN.Vol19No02Man02

22.

Intrator

Miller

E. A.

Gadbois

Acquah

J. K.

Makineni

Tyler

(2015). Trends in nurse practitioner and physician assistant practice in nursing homes, 2000–2010. Health Services Research, 50(6), 1772-1786. https://doi.org/10.1111/1475-6773.12410

23.

Kaplan

Skillman

S. M.

Fordyce

M. A.

McMenamin

P. D.

Doescher

M. P.

(2012). Understanding APRN distribution in the United States using NPI data. Journal for Nurse Practitioners, 8(8), 626-635. https://doi.org/10.1016/j.nurpra.2012.05.022

24.

Kleiner

M. M.

Marier

Park

K. W.

Wing

(2016). Relaxing occupational licensing requirements: analyzing wages and prices for a medical service. The Journal of Law and Economics, 52(2), 1-53.

25.

Knepper

Sonenberg

Levine

(2015). Cost savings of diabetes outcomes: Impact of nurse practitioner practice regulatory policy. International Journal of Services and Standards, 10(1-2), 17-31. https://doi.org/10.1504/IJSS.2015.068061

26.

Frogner

B. K.

Steinmetz

Pittman

(2015). Community health centers employ diverse staffing patterns, which can provide productivity lessons for medical practices. Health Affairs, 34(1), 95-103. https://doi.org/10.1377/hlthaff.2014.0098

27.

Kuo

Y. F.

Loresto

F. L.

Jr. Rounds

L. R.

Goodwin

J. S.

(2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs, 32(7), 1236-1243. https://doi.org/10.1377/hlthaff.2013.0072

28.

Kurtzman

E. T.

Barnow

B. S.

Johnson

J. E.

Simmens

S. J.

Infeld

D. L.

Mullan

(2017). Does the regulatory environment affect nurse practitioners’ patterns of practice or quality of care in health centers? Health Services Research, 52(S1), 437-458. https://doi.org/10.1111/1475-6773.12643

29.

Ladd

Sweeney

C. F.

Guarino

Hoyt

(2017). Opioid prescribing by nurse practitioners in Medicare part D: Iimpact of state scope of practice legislation. Medical Care Research and Review, 76(3), 337-353. https://doi.org/10.1177/1077558717725604

30.

Leszinsky

Candon

(2019). Primary care appointments for Medicaid beneficiaries with advanced practitioners. Annals of Family Medicine, 17(4), 363-366. https://doi.org/10.1370/afm.2399

31.

Levy

Epstein

Landry

Kramer

(2005). Literature review and synthesis of physician practices in nursing homes. https://aspe.hhs.gov/basic-report/literature-review-and-synthesis-physician-practices-nursing-homes

32.

McCleery

Christensen

Peterson

Humphrey

Helfand

(2014). Evidence brief: The quality of care provided by advanced practice nurses. U.S. Department of Veterans Affairs.

33.

McMichael

B. J.

Safriet

B. J.

Buerhaus

P. I.

(2018). The extraregulatory effect of nurse practitioner scope-of-practice laws on physician malpractice rates. Medical Care Research and Review, 75(3), 312-326. https://doi.org/10.1177/1077558716686889

34.

McMichael

B. J.

Spetz

Buerhaus

P. I.

(2019). The association of nurse practitioner scope of practice laws with emergency department use: Evidence from Medicaid expansion. Medical Care, 57(5), 362-368. https://doi.org/10.1097/MLR.0000000000001100

35.

Mobley

L. R.

Subramanian

Tangka

F. K.

Hoover

Wang

Hall

I. J.

Singh

S. D.

(2017). Breast cancer screening among women with Medicaid, 2006–2008: A multilevel analysis. Journal of Racial and Ethnic Health Disparities, 4(3), 446-454. https://doi.org/10.1007/s40615-016-0245-9

36.

Modesti

P. A.

Reboldi

Cappuccio

F. P.

Agyemang

Remuzzi

Rapi

Perruolo

Parati

(2016). Panethnic differences in blood pressure in Europe: A systematic review and meta-analysis. PLoS ONE, 11(1), Article e0147601. https://doi.org/10.1371/journal.pone.0147601

37.

Morgan

P. A.

Strand

Ostbye

Albabese

M. A.

(2008). Missing in action: Care by physician assistants and nurse practitioners in national health surveys. Health Services Research, 42(5), 2022-2037. https://doi.org/10.1111/j.1475-6773.2007.00700.x

38.

Naylor

M. D.

Kurtzman

E. T.

(2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899. https://doi.org/10.1377/hlthaff.2010.0440

39.

Neff

D. F.

Yoon

S. H.

Steiner

R. L.

Bejleri

Bumbach

M. D.

Everhart

Harman

J. S.

(2018). The impact of nurse practitioner regulations on population access to care. Nursing Outlook, 66(4), 379-385. https://doi.org/10.1016/j.outlook.2018.03.001

40.

Newhouse

R. P.

Stanik-Hutt

White

K. M.

Johantgen

Bass

E. B.

Zangaro

Wilson

R. F.

Fountain

Steinwachs

D. M.

Heindel

Weiner

J. P.

(2011). Advanced practice nurse outcomes 1990-2008: A systematic review. Nurse Economics, 29(5), 230-250.

41.

Park

Athey

Pericak

Pulcini

Greene

(2018). To what extent are state scope of practice laws related to nurse practitioners’ day-to-day practice autonomy? Medical Care Research and Review, 75(1), 66-87. https://doi.org/10.1177/1077558716677826

42.

Park

Han

Pittman

(2020). Does expanded state scope of practice for nurse practitioners and physician assistants increase primary care utilization in community health centers? Journal of the American Association of Nurse Practitioners, 32(6), 447-458. doi: 10.1097/JXX.0000000000000263

43.

Patel

E. Y.

Petermann

Mark

B. A.

(2019). Does state-level nurse practitioner scope of practice policy affect access to care? Western Journal of Nursing Research, 41(4), 488-518. https://doi.org/10.1177/0193945918795168

44.

Perloff

Clarke

DesRoches

C. M.

O’Reilly-Jacob

Buerhaus

(2017). Association of state-level restrictions in nurse practitioner scope of practice with the quality of primary care provided to Medicare beneficiaries. Medical Care Research and Review, 76(5), 597-626. https://doi.org/10.1177/1077558717732402

45.

Perloff

DesRoches

C. M.

Buerhaus

(2016). Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Services Research, 51(4), 1407-1423. https://doi.org/10.1111/1475-6773.12425

46.

Perry

J. J.

(2012). State-granted practice authority: Do nurse practitioners vote with their feet? Nursing Research and Practice, 2012, Article e482178. https://doi.org/10.1155/2012/482178

47.

Pittman

Leach

Everett

Han

McElroy

(2018). NP and PA privileging in acute care settings: Do scope of practice laws matter? Medical Care Research and Review, 77(2), 112-120. https://doi.org/10.1177/1077558718760333

48.

Poghosyan

Timmons

Abraham

Martsolf

G. R.

(2019). The economic impact of the expansion of nurse practitioner scope of practice for Medicaid. Journal of Nursing Regulation, 10(1), 15-20. https://doi.org/10.1016/S2155-8256(19)30078-X

49.

Reagan

P. B.

Salsberry

P. J.

(2013). The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners. Nursing Outlook, 61(6), 392-399. https://doi.org/10.1016/j.outlook.2013.04.007

50.

Schirle

McCabe

B. E.

(2016). State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states. Nursing Outlook, 64(1), 86-93. https://doi.org/10.1016/j.outlook.2015.10.003

51.

Smith-Gagen

White

L. L.

Santos

Hasty

S. M.

Tung

W. C.

(2019). Scope of practice laws and expanded health services: The case of underserved women and advanced cervical cancer diagnoses. Journal of Epidemiology & Community Health, 73(3), 278-284. https://doi.org/10.1136/jech-2018-210709

52.

Spetz

Parente

S. T.

Town

R. J.

Bazarko

(2013). Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics. Health Affairs, 32(11), 1977-1984. https://doi.org/10.1377/hlthaff.2013.0544

53.

Spetz

Toretsky

Chapman

Phoenix

Tierney

(2019). Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions. Journal of the American Medical Association, 321(14), 1407-1408. https://doi.org/10.1001/jama.2019.0834

54.

Stange

(2014). How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. Journal of Health Economics, 33(1), 1-27. https://doi.org/10.1016/j.jhealeco.2013.10.009

55.

Stanik-Hutt

Newhouse

R. P.

White

K. M.

Johantgen

M. E.

Bass

E. B.

Zangaro

Wilson

Fountain

Steinwachs

D. M.

Heindel

Weiner

J., P

. (2013). The quality and effectiveness of care provided by nurse practitioners. Journal of Nurse Practitioners, 9(8), 492-500. https://doi.org/10.1016/j.nurpra.2013.07.004

56.

Timmons

E. J.

(2017). The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care. Health Policy, 121(2), 189-196. https://doi.org/10.1016/j.healthpol.2016.12.002

57.

Traczynski

Udalova

(2018). Nurse practitioner independence, health care utilization, and health outcomes. Journal of Health Economics, 58(1), 90-109. https://doi.org/10.1016/j.jhealeco.2018.01.001

58.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, & National Center for Health Workforce Analysis. (2016). National and regional projections of supply and demand for primary care practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/primary-care-national-projections2013-2025.pdf

59.

U.S. Department of Veterans Affairs. (2016). VA grants full practice authority to advanced practice registered nurses. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847

60.

Wells

G. A.

Shea

O’Connell

Peterson

Welch

Losos

Tugwell

(n.d.). The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

61.

Wing

Simon

Bello-Gomez

R., A

. (2018). Designing difference in difference studies: Best practices for public health policy research. Annual Review of Public Health, 39, 453-469. https://doi.org/10.1146/annurev-publhealth-040617-013507

62.

Wolff-Baker

Ordona

R. B.

(2019). The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. Journal of Gerontology Nursing, 45(6), 9-14. https://doi.org/10.3928/00989134-20190422-01

63.

Xue

Kannan

Greener

Smith

J. A.

Brasch

Johnson

B. A.

Spetz

(2018). Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. Journal of Nursing Regulation, 8(4), 5-13. https://doi.org/10.1016/S2155-8256(17)30176-X

64.

Xue

Brewer

Spetz

(2016). Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook, 64(1), 71-85. https://doi.org/10.1016/j.outlook.2015.08.005

65.

Yang

B. K.

Trinkoff

A. M.

Zito

J. M.

Burcu

Safer

D. J.

Storr

C. L.

Johantgen

M. E.

Idzik

(2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. community health centers. Psychiatric Services, 68(10), 1032-1038. https://doi.org/10.1176/appi.ps.201600495

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.80 MB