Article Practice| Volume 62, ISSUE 6, P440-447, November 2014

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Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients


      Strengthening health care overall is essential to the health of our nation and promoting access to health care as well as controlling health care costs in a quality cost-effective manner. Nurse practitioners have demonstrated to be effective and cost-effective providers in prior research; however, many states restrict their practice. We examined for a statistically significant relationship between the level of advanced practice registered nurse (APRN) practice (full, reduced, or restricted) allowed and results of recent nationwide, state level analyses of Medicare or Medicare-Medicaid beneficiaries of potentially avoidable hospitalizations, readmission rates after inpatient rehabilitation, and nursing home resident hospitalizations and then compared them with state health outcome rankings. States with full practice of nurse practitioners have lower hospitalization rates in all examined groups and improved health outcomes in their communities. Results indicate that obstacles to full scope of APRN practice have the potential to negatively impact our nation's health. Action should be taken to remove barriers to APRN practice.


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      1. American Academy of Family Physicians. (2012). Primary care for the 21st century: Ensuring a quality physician-led team for every patient. Retrieved from

      2. American Association of Nurse Practitioners. (2013). 2013 nurse practitioner state practice environment. Retrieved from

        • American Medical Association
        AMA scope of practice data series: Nurse practitioners.
        American Medical Association, Chicago2009
      3. APRN Joint Dialogue Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from

        • Auerbach D.I.
        • Chen P.G.
        • Friedberg M.W.
        • Reid R.
        • Lau C.
        • Buerhause P.I.
        • Mehrota A.
        • et al.
        Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage.
        Health Affairs. 2013; 32: 1933-1941
      4. California Health Care Foundation. (2014). US health care spending: Who pays. Retrieved from

      5. Centers for Disease Control and Prevention. (2013). Annual number (in thousands) of new cases of diagnosed diabetes among adults aged 18–79 years, United States, 1980-2011. Retrieved from

        • Donelan K.
        • DesRoches C.M.
        • Dittus R.S.
        • Buerhaus P.
        Perspectives of physicians and nurse practitioners on primary care practice.
        New England Journal of Medicine. 2013; 368: 1898-1906
        • Dower C.
        • Moore J.
        • Langelier M.
        It is time to restructure health professions scope-of-practice regulations to remove barriers to care.
        Health Affairs. 2013; 32: 1971-1976
        • Duckworth J.M.
        • Repede E.
        • Elliott L.
        Nurse practitioners aiding frail elderly through home visits.
        Home Health Care Management & Practice. 2013; 25: 212-216
      6. Gilman, D. J., & Koslov, T. I. (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from

        • Hayes W.L.
        Holt, Rinehart and Winston, New York1988
        • Horrocks S.
        • Anderson E.
        • Salisbury C.
        Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.
        British Medical Journal. 2002; 324: 819-823
        • Institute of Medicine
        The future of nursing: Leading change, advancing health.
        The National Academies Press, Washington, DC2011
      7. Kaiser Family Foundation. (2014). Retrieved from

        • Konetzka R.T.
        • Spector W.
        • Limcangco M.R.
        Reducing hospitalizations from long-term care settings.
        Medical Care Research and Review. 2008; 64: 40-66
        • Kuo Y.
        • Loresto F.L.
        • Rounds L.R.
        • Goodwin J.S.
        The states with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners.
        Health Affairs. 2013; 32: 1236-1243
        • Laurant M.
        • Reeves D.
        • Hermens R.
        • Braspenning J.
        • Grol R.
        • Sibbald B.
        Substitution of doctors by nurses in primary care.
        Cochrane Database of Systematic Reviews. 2005; 4 (Art. No.: CD001271): 1-41
        • Lenz E.R.
        • Mundinger M.O.
        • Kane R.L.
        • Hopkins S.C.
        • Lin S.X.
        Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up.
        Medical Care Research and Review. 2004; 61: 332-351
        • Mundinger M.O.
        • Kane R.L.
        • Lenz E.R.
        • Totten A.M.
        • Tsai W.Y.
        • Cleary P.D.
        • Shelanski M.L.
        • et al.
        Primary care outcomes in patients treated by nurse practitioners or physicians.
        Journal of the American Medical Association. 2000; 283: 59-68
        • National Governor's Association Center for Best Practices
        (Retrieved from)
        • Naylor M.D.
        • Kurtzman E.T.
        The role of nurse practitioners in reinventing primary care.
        Health Affairs. 2010; 29: 893-899
        • Newhouse R.P.
        • Stanik-Hunt J.
        • White K.M.
        • Johantgen M.
        • Bass E.B.
        • Zangaro G.
        • Weiner J.P.
        • et al.
        Advanced practice nurse outcomes 1990-2008: A systematic review.
        Nursing Economics. 2011; 29: 230-250
        • O'Grady E.T.
        Advanced practice registered nurses: The impact on patient safety and quality.
        in: Hughes R.G. Patient safety and quality: An evidence-based handbook for nurses. AHRQ Publication No. 08-0043, 2008: 1-20 (chapter 43. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from)
        • Oliver G.
        • Pennington L.
        • Revelle S.
        Nurse practitioners and national health outcomes.
        Missouri Nurse. 2014; 83: 13-16
        • Ottenbacher K.J.
        • Karmarker A.
        • Graham J.E.
        • Kuo Y.F.
        • Deutsch A.
        • Reistetter T.A.
        • Granger C.V.
        • et al.
        Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.
        Journal of the American Medical Association. 2014; 311: 604-614
        • Peterson S.M.
        • Liaw W.R.
        • Phillips R.L.
        • Rabin D.L.
        • Meyers D.S.
        • Bazemore A.W.
        Projecting US primary care physician workforce needs: 2010-2025.
        Annals of Family Medicine. 2012; 10: 503-509
        • Phillips S.
        After 20 years, APNs are still standing together.
        Nurse Practitioner. 2008; 33: 10-13
        • Rantz M.
        • Alexander G.
        • Galambos C.
        • Vogelsmeier A.
        • Popejoy L.
        • Flesner M.
        • Zwygart-Stauffacher M.
        • et al.
        Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents.
        Journal of Nursing Care Quality. 2013; 29: 1-8
      8. Robert Wood Johnson Foundation. (2013). Improving patient access to high quality care. Retrieved from

        • Safriet B.J.
        Health care dollars and regulatory sense: The role of advanced practice nursing.
        The Yale Journal of Regulation. 1992; 9: 417-488
        • Segal M.
        • Rollins E.
        • Hodges K.
        • Roozeboom M.
        Medicare-Medicaid eligible beneficiaries and potentially avoidable hospitalizations.
        Medicare & Medicaid Research Review. 2014; 4: E1-E13
      9. Traczynski, J. & Udalova, V. (2013, April). Nurse practitioner independence, health care utilization, and health outcomes. Paper presented at the Fourth Annual Midwest Health Economics Conference, Madison, WI.

      10. United Health Foundation. (2012). America's health rankings: A call to action for individuals and their communities (23rd ed.). Retrieved from

        • U.S. Congress Office of Technology Assessment
        Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. (Health Technology Case Study 37), OTA-hcs-37.
        U.S. Government Printing Office, Washington, DC1986
      11. U.S. Department of Health and Human Services. (2013). How the healthcare law benefits you. Retrieved from

      12. U.S. Department of Health & Human Services. (2014). Strategic plan and priorities. Retrieved from

      13. U.S. Department of Health and Human Services Office of Inspector General. (2013). Medicare nursing home resident hospitalization rates merit additional monitoring. (OEI-06–00040). Retrieved from