A new study has found that antibodies that guard against coronavirus disease 2019 (COVID-19) can transfer from mothers to babies while in the womb, according to researchers from Weill Cornell Medicine and New York-Presbyterian.

American Journal of Obstetrics and Gynecology

, the discovery adds to growing evidence that suggests that pregnant women who generate protective antibodies after contracting the COVID-19 virus often convey some of that natural immunity to their fetuses. The findings also support that vaccinating mothers-to-be may have benefits for their newborns, according to the study authors.

“Since we can now say that the antibodies pregnant women make against COVID-19 have been shown to be passed down to their babies, we suspect that there’s a good chance they could pass down the antibodies the body makes after being vaccinated as well,” said senior study author Yawei Jenny Yang, MD, an assistant professor of pathology and laboratory medicine at Weill Cornell Medicine, in a press release.

The research team analyzed blood samples from 88 women who gave birth at New York-Presbyterian/Weill Cornell Medical Center between March and May 2020 during the time in which New York City was the global epicenter of the pandemic. All of the women had COVID-19 antibodies in their blood, indicating that they had contracted the virus at some point, even though 58% of those women had no symptoms, according to the study authors.

Further, although antibodies were detected in both symptomatic and asymptomatic women, the researchers observed that the concentration of antibodies was significantly higher in symptomatic women. They also found that the general pattern of antibody response was similar to the response seen in other patients, confirming that pregnant women have the same kind of immune response to the virus as the larger patient population, which was not previously known due to women’s immune system changes throughout pregnancy.

In addition, the vast majority of the babies born to these women (78%) had detectable antibodies in their umbilical cord blood. The researchers said they found no evidence that any of the infants had been directly infected with the virus and all were COVID-19-negative at the time of birth, further indicating that the antibodies had crossed the placenta, the organ that provides oxygen and nutrients to a growing baby during pregnancy, into the fetal bloodstream. Newborns with symptomatic mothers also had higher antibody levels than those whose mothers had no COVID-19 symptoms, according to the study authors.

These data imply that pregnant women could pass along vaccine-generated antibodies in the same way, potentially shielding both mother and child from future infection. However, it is not yet known exactly how protective these antibodies might be or how long that protection might last.

Study co-author Laura Riley, MD, chair of the department of obstetrics and gynecology at Weill Cornell Medicine, obstetrician and gynecologist-in-chief at New York-Presbyterian/Weill Cornell, is still advising pregnant patients who decide to get vaccinated to continue to follow current safety guidelines to prevent the spread of the disease.

Follow-up investigations are enrolling pregnant women who receive the vaccine, as well as vaccinated mothers who are breastfeeding, to assess the antibody response in these groups after vaccination. This information could help guide maternal vaccination strategies moving forward, according to the study authors.

Researchers learn that pregnant women pass along protective COVID antibodies to their babies. Weill Cornell Medicine. 

https://news.weill.cornell.edu/news/2021/02/researchers-learn-that-pregnant-women-pass-along-protective-covid-antibodies-to-their

. Published February 22, 2021. Accessed February 24, 2021.

The discovery adds to growing evidence that suggests that pregnant women who generate protective antibodies after contracting the COVID-19 virus often convey some of that natural immunity to their fetuses. 

Study: Pregnant Women Pass Along Protective COVID-19 Antibodies to Babies

Jill Murphy, Associate Editor

Jennifer Hofmann, DMSc, MS, PA-C, and Jean Covino, DHSc, MPA, PA-C

The Advisory Committee on Immunization Practices (ACIP) recommends that all Americans 6 months and older who do not have contraindications receive the flu vaccine.

Health care providers should recommend the high-dose or adjuvanted flu vaccine for patients 65 and older. These 2 types of the vaccine are designed to spur a stronger immune response. The difference between adjuvanted and high-dose vaccines is that the adjuvanted vaccine is made with MF59 adjuvant, which is designed to enhance the immune response. The high-dose vaccine is designed for patients 65 and older and contains 4 times the amount of antigen as the regular flu vaccine. As such, it is associated with a stronger immune response, and patients who received the high-dose vaccine had 24% fewer influenza infections compared with those who received the standard-dose flu vaccine.

Children aged 6 months to 8 years who have never received the vaccine should receive 2 doses, the first as soon as it is available and the second about a month later.

showed that the vaccine significantly reduces a child’s risk of dying from the influenza virus. The study looked at data from 2010 to 2014 and found that the vaccine reduced the risk of flu-associated death by 51% among children with underlying high-risk medical conditions. Just 1 in 4 children who reportedly died from influenza had received the vaccine. As of March, 61 pediatric flu-related deaths had been reported in 2017.

From 1982-2016, peak influenza activity did not occur until January or later, but it can start as early as October.

Considering inconclusive evidence that delaying immunization may increase immunity in the latter half of the flu season, the ACIP recommends that patients get vaccinated early. The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

A potential safety signal associated with the flu vaccination of pregnant women has been raised. A case control study has reported that women early in pregnancy who have been vaccinated with vaccine containing the H1N1 component had a higher rate of spontaneous abortion within 28 days of vaccination. However, the ACIP has not changed its re

commendation on not vaccinating pregnant women in any trimester. There is an ongoing study involving pregnant patients and the flu vaccine that should produce results by 2018 or 2019.

According to the CDC, the flu vaccine is associated with decreased hospitalizations among patients with diabetes (79%) and chronic lung disease (52%).

Additionally, a meta-analysis suggests that the influenza vaccine is associated with a lower risk of major cardiovascular events in patients with active coronary disease.

With these statistics in mind, health care providers should be the most prominent advocates of the flu vaccine, especially concerning these special patient populations.

Another concern when considering the flu vaccine in certain patient populations is an egg allergy. The ACIP recommends that patients who have experienced urticaria after exposure to eggs should be vaccinated. Patients who have experienced severe reactions to eggs, such as angioedema or respiratory distress, or who require epinephrine, may receive any licensed and recommended flu vaccine. However, vaccine administration should be supervised by a health care provider who is trained to manage severe allergic reactions. As always, patients who have suffered an allergic reaction to the flu vaccine previously should not receive the vaccine.

One option for patients with severe egg allergies is Flublok, a vaccine that is not produced using chicken eggs. If a patient asks for the Flublok vaccine, it should be noted that the vaccine has a slightly shorter shelf life of 9 months from the production date.

Always remember the CDC’s SHARE method: Share the reasons that the influenza vaccine is right for patients, highlight positive experiences with the vaccine, address all patient questions, remind patients that influenza vaccines protect them and their loved ones, and explain the potential costs of getting the flu. It is important that patients understand the vaccine and the reasoning behind its recommendation so that they can make informed decisions about the flu and other vaccines.

Pharmacists, nurse practitioners, physician assistants, and physicians are vital to increasing influenza immunization rates. Patients trust health care providers to provide the latest evidence involving the vaccine and data surrounding special patient populations.

is a community pharmacy resident at the University of Georgia and Kroger Pharmacy.

1. CDC. Prevention and control of influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013-2014.

2. What you should know and do this flu season if you are 65 years and older. CDC website.

. Updated October 13, 2017. Accessed November 2, 2017.

3. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season.

4. CDC study finds flu vaccine saves children’s lives [news release].  CDC. April 3, 2017.

cdc.gov/media/releases/2017/p0403-flu-vaccine.html

5. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 influenza season.

2017;66(2):1-20. doi: 10.15585/mmwr.rr6602a1.

6. Flu vaccination & possible safety signal. CDC website.

cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html

. Updated September 13, 2017. Accessed November 2, 2017.

Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis.

8. Flu vaccine and people with egg allergies. CDC website.

cdc.gov/flu/protect/vaccine/egg-allergies.htm

. Updated September 2, 2016. Accessed November 2, 2017.

9. Flublok seasonal influenza (flu) vaccine. CDC website.

cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm

. Updated October 3, 2017. Accessed November 2, 2017.

10. When & how to wash your hands. CDC website.

cdc.gov/handwashing/when-how-handwashing.html

. Updated March 7, 2017. Accessed November 2, 2017.

The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

Influenza Prevention: Make Sure Patients Understand the Vaccine

Abby Case, PharmD

April is Alcohol Awareness Month, and we have simplified science on everything related—effects on the body, nutrition, and how an individual can still be on a quest with sound nutrition, making sense of how alcohol and calories mix. Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say, to better arm healthcare providers, and to help patients.

named April National Alcohol Awareness Month in 1987 as a way to decrease the stigma associated with alcoholism, and to provide education to prevent unnecessary health risks.

There are some key terms, definitions, and implications that will prove helpful for healthcare providers to know, so that they can better educate their patients on alcohol, its effects, and the implications of certain drinking patterns.

National Council on Alcoholism and Drug Dependence

Excessive drinking is associated with a significant increase in acute health and safety risks, proportional to the amount of alcohol consumed. If this behavior becomes habitual, then over time it can lead to many other health complications.

Patients often times have questions related to alcohol, its effects on medications, diet, and their health, so what better time to dive into this topic and share what the science has to say.

The Buzz On Alcohol and the Body

Adam Martin, PharmD, ACSM-CPT

Death by external causes&#151;primarily accidents and suicide—take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures.

In Japan, a country boasting one of the highest life expectancies across the globe, a recent study found that external causes take the lives of women 10 years earlier than those by all other causes. The study sought to investigate the association between female reproductive factors, and the risk of external causes of death among middle-aged women in Japan.

The study followed 49,279 women for 20 years; 8477 of the women died, and the researchers collected their death certificates to confirm their causes of death. Of these deaths, 328 were by external causes: 148 by suicide, and 167 by accident. The researchers found that women designated “ever parous” (carrying at least one pregnancy to 24 weeks) had a lower risk of suicide than those designated “never parous.” They also found that parous women who had ever breastfed were much less likely to die by accident.

The study suggests that the decreased risk of suicide in “ever parous” women is consistent with previous studies. They indicate that the presence of a child may significantly deter the decision to commit suicide, especially while the child is dependent.

In addition, researchers found that the lower risk of accidents seen among postmenopausal women may be linked to the protective effect of breastfeeding on osteoporosis, and subsequent fracture occurrences. Osteoporosis can turn a simple fall into a health crisis, ultimately traced back to an accident.

The study concludes that “suicide and accidents are never the consequence of a single cause; a combination of personal, cultural, social, and biological features likely interact with fluctuations in sex hormones among women.” The researchers acknowledge that the reproductive factors they studied are not modifiable, but emphasize that a better understanding could still help to reduce avoidable deaths by self-harm and accidents.

is a 2023 PharmD Candidate at the University of Connecticut in Storrs.

Female reproductive factors and risk of external causes of death among women: The Japan Public Health Center-based Prospective Study (JPHC Study).

9, 14329 (2019) doi:10.1038/s41598-019-50890-x

Death by external causesâ€”primarily accidents and suicideâ€”take the lives of more than 5 million people each year, and it has evolved into a major health concern on a global scale. External causes also include violence, undetermined causes, and medical procedures. 
 

Breastfeeding and Parity Linked to Lower Risk of Death by Accidents and Suicide

Adara Bochanis, PharmD Candidate

Patients with type 2 diabetes (T2D) who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Researchers from the Imperial College London analyzed 7 years’ worth of flu-season data on nearly 125,000 patients with T2D seen in primary care clinic. They found that individuals who received the flu shot were 30% less likely to be admitted to the hospital for stroke, 22% less likely to be admitted for heart failure, and 15% less likely to be admitted for pneumonia or influenza than their unvaccinated counterparts.

Patients who received the flu shot also had a 24% reduced risk of all-cause mortality.

To better understand the effect of the flu vaccine on a patient’s risk for hospitalization, the researchers controlled for patients’ age, weight, smoking status, and gender. Also important to the researchers was whether or not patients had been diagnosed with or were taking prescriptions for other long-term chronic conditions, such as heart disease and asthma.

that individuals at high risk of serious flu complications include young children; pregnant women; patients with chronic health conditions like asthma, diabetes, or heart and lung disease; and those 65 years and older.

“The potential impact of influenza vaccine to reduce serious illness and death highlight the importance to renew efforts to ensure that people with diabetes receive the flu vaccine every year,” lead study author Eszter Vamos, a public health researcher at Imperial College London, told

The researchers noted that one study limitation is that those who opt to get the flu shot may be healthier overall, meaning they already had a reduced risk for hospitalization or death.

Causation notwithstanding, the best protection for those with chronic conditions is preventing the flu in the first place.

Nurse practitioners and retail clinicians should remind every patient at every visit about the importance of the flu shot.

Patients with type 2 diabetes who get the flu shot may have a reduced risk for hospitalization related to cardiovascular or respiratory issues, recent research suggests.

Flu Shot May Help Diabetes Patients Avoid Hospitalization, Death

Aine Cryts

The FDA has issued a letter to JUUL Labs Inc, requesting more information about the company&#39;s outreach and marketing practices of electronic nicotine delivery systems (ENDS) and related products. The letter specified concerns around marketing targeted at students. The FDA also issued a simultaneous warning letter regarding JUUL&#39;s marketing and advertising practices.

According to FDA policies, companies must scientifically demonstrate that their products pose less risk than traditional products before they are able to market products for reduced risk. Acting FDA Commissioner Ned Sharpless, MD, said JUUL has ignored this law in marketing their products.

The warning letter cited several statements examined during a July 2019 Congressional hearing on JUUL products. According to the testimony, a JUUL representative speaking with students at a school made statements that identified JUUL products as "much safer than cigarettes," and that a student "should mention JUUL to his [nicotine-addicted] friend...because that&#39;s a safer alternative than smoking cigarettes, and it would be better for the kid to use."

"The agency is concerned these statements and representations may convey that switching to JUUL is a safer alternative to cigarettes, in that using JUUL products poses less risk or is less harmful than cigarettes," said the FDA statement.

E-cigarette use has been under increasing scrutiny over the past year. The FDA conducted a

in October 2018, after concerns were raised regarding e-cigarette sales to minors.

was recorded in August 2019, according to the Illinois Department of Public Health.

According to the CDC, JUUL sales have rapidly increased since 2016. Between 2016 and 2017, JUUL sales increased from 2.2 million devices sold to 16.2 million devices, a total increase of 641%. The CDC expressed concern that 74% of youth who used JUUL said they bought the device directly from a retail store.

Like the CDC, the FDA also expressed concern regarding youth&#39;s perceptibility to marketing of e-cigarette products.

"Referring to your ENDS products as &#39;99% safer&#39; than cigarettes, &#39;much safer&#39; than cigarettes, &#39;totally safe,&#39; and &#39;a safer alternative than smoking cigarettes,&#39; is particularly concerning because these statements were made directly to children in school," the warning letter said. "Our concern is amplified by the epidemic rate of increase in youth use of ENDS products, including JUUL&#39;s products, and evidence that ENDS products contribute to use of, and addiction to, nicotine, to which youth are especially vulnerable."

The FDA requested documents and information on several issues, including JUUL&#39;s use of nicotine salts in its e-liquids and the concentration of nicotine in its products. Nicotine salts were described at the Congressional hearing as a tool to mask the harshness of nicotine.

The FDA also asked JUUL to provide information on why they use a nicotine concentration of 5% in their products, which could potentially increase addictiveness.

The FDA has requested that JUUL provide the requested documents and information within 30 days of the letter.

FDA warns JUUL Labs for marketing unauthorized modified risk tobacco products, including in outreach to youth [news release]. Silver Spring, MD; September 9, 2019: FDA website. https://www.fda.gov/news-events/press-announcements/fda-warns-juul-labs-marketing-unauthorized-modified-risk-tobacco-products-including-outreach-youth. Accessed September 9, 2019.

FDA Takes New Steps to Address Epidemic of Youth E-Cigarette Use, Including a Historic Action Against More than 1300 Retailers and 5 Major Manufacturers for their Roles Perpetuating Youth Access [news release]. Silver Spring, MD; September 11, 2018: FDA website. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/UCM620184.htm. Accessed September 9, 2019.

Illinois Resident Experiencing Respiratory Illness After Vaping Dies. Springfield, Illinois [news release]. Springfield, IL; August 23, 2019: IDPH website. https://www.dph.illinois.gov/news/illinois-resident-experiencing-respiratory-illness-after-vaping-dies. Accessed August 26, 2019.

Sales of JUUL E-cigarettes Skyrocket, Posing Danger to Youth [news release]. Atlanta, GA; October 2, 2018: CDC Newsroom. https://www.cdc.gov/media/releases/2018/p1002-e-Cigarette-sales-danger-youth-html. Accessed October 2, 2018.

Sharpless N. JUUL Labs, Inc. - 509050 - 09/09/2019. Silver Spring, MD; September 9, 2019: FDA website. https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/juul-labs-inc-590950-09092019. Accessed September 9, 2019.

The FDA has issued a letter to JUUL Labs Inc, requesting more information about the company's outreach and marketing practices of electronic nicotine delivery systems (ENDS) and related products. The letter specified concerns around marketing targeted at students. The FDA also issued a simultaneous warning letter regarding JUUL's marketing and advertising practices.

FDA Warns E-Cigarette Company of Advertising, Marketing Concerns

Aislinn Antrim

New research suggests that ‘smart’ asthma inhaler sensors may improve control of asthma in children as well as improving the quality of life for caregivers. According to Ann & Robert H. Lurie Children’s Hospital of Chicago, this intervention should be considered to help engage diverse populations of pediatric asthma patients.

More than 25 million Americans are diagnosed with asthma and most are prescribed inhalers that are designed to prevent and treat asthma attacks. Most patients can achieve disease control with effective management and live symptom-free. However, patients with moderate-to-severe disease, asthma control may also require use of ‘controller’ medications as well as occasional use of ‘rescue’ medications.

Connected inhalers, or ‘smart’ inhalers, use Bluetooth sensors that attach to participants’ asthma inhalers to detect medication use, and they share data with physicians. According to the study results, the data could help improve treatment decisions, and these inhalers could also promote adherence to recommended controller medication use and proactively detect worsening of asthma symptoms.

“Emerging connected technologies can help improve patient health, with this randomized-controlled clinical trial showing that pediatric asthma patients with access to inhaler sensors report better asthma control and quality of life than patients who only received a standardized asthma education curriculum,” said study lead Ruchi Gupta, MD, in a statement.

The study included 252 children with moderate or persistent asthma who were recruited from 5 clinics. They were 24% non-Hispanic white, 23% non-Hispanic Black, and 40% Hispanic, while 60% were on public insurance. The study lasted 1 year and had assessments at enrollment, 3 months, 6 months, 9 months, and 12 months.

Study participants were evaluated based on an Asthma Control Test questionnaire, which measured their asthma symptom control on a scale from 0 (poor control) to 27 (well-controlled). According to the Lurie children’s hospital, average scores among those who received the intervention increased by 10.1% over the course of the study. The researchers noted the greatest improvements among non-Hispanic Black participants.

Caregivers were assessed with their own questionnaire, which measured how the sensor-based monitoring adherence affected their day-to-day involvement. They reported improved quality of life after the first month of the study due to easier asthma management, which was sustained through the year-long trial.

“This study is another clear example that digital health is here to stay, as it allows for us to stay connected to patients living with chronic disease, provide a level of automated watchfulness, and intercept disease in a timely measure,” said Deneen Vojta, MD, chief physician executive for Optum Labs, in a statement. “This is a terrific example of moving from the best care out there today to the best care possible.”

“Smart” Asthma Inhaler Sensors Improve Pediatric Asthma Control [news release]. Ann and Robert H. Lurie Children’s Hospital of Chicago; February 17, 2021. Accessed February 18, 2021. 

https://www.luriechildrens.org/en/news-stories/smart-asthma-inhaler-sensors-improve-pediatric-asthma-control/

Investigators found the greatest improvements among non-Hispanic Black participants, suggesting that the intervention could help engage diverse populations of pediatric asthma patients.

Study Finds Sensor-Based Inhalers Improve Asthma Control in Children

Aislinn Antrim, Associate Editor

During the coronavirus disease 2019 (COVID-19) pandemic, many patients in the United States reduced the number of in-person preventive and elective health care visits and increased the number of telemedicine appointments. However, an analysis of the data from March and April 2020, which were the first 2 months of the COVID-19 pandemic lockdown, found that the switch to telemedicine was not sufficient enough to offset the overall reduction in visits.

The analysis of the data was pulled from the medical records of approximately 5 million Americans with private health insurance and demonstrated that the number of mammograms and colonoscopies decreased by approximately 65%, as these types of elective medical care were not easily transferable to a telemedicine format. Overall, use of preventive and elective health care by patients declined by 23% in March and by 52% in April.

However, in lower-income or predominately non-white zip codes, there was a lower reduction in in-person care in addition to lower rates of telemedicine use. The authors who published these findings in 

 noted that this is another example of how the COVID-19 pandemic intensified existing disparities related to health care.

"This adds detailed evidence to the anecdotal reports that Americans quit going to see the doctor when the pandemic shutdown started," said lead author Christopher Whaley, PhD, a policy researcher at the nonprofit research organization RAND Corporation, in a press release. "If important visits are only delayed for a few months, there will likely be no harm. But if patients do not get important screenings, there could be long-term negative health consequences."

Although other studies have analyzed data from this same period, most have assessed data from a single health system or geographic market in order to observe the impact of COVID-19 on the utilization of medical services. In this study conducted by Whaley and his colleagues, the researchers used insurance claims data from 2018 to 2020 from approximately 200 employers across the country.

The results of the study demonstrated that when compared to the rates in March and April 2019, colonoscopies decreased by approximately 70% during March and April 2020. When conducting the same comparison for mammograms, the researchers observed a 67% decrease among women aged 46 to 64 years.

Additionally, utilization of blood sugar tests decreased by approximately 50%, vaccinations among children under age 2 decreased by 22%, and angioplasty procedures decreased by approximately 17%. Surgeries such as musculoskeletal surgery and cataract surgery, as well as MRIs, all decreased by 45% or more. However, only a small decreased was observed in utilization of chemotherapy treatments.

In April 2020, use of telemedicine appointments increased by over 4000% when compared to April 2019. Yet, this significant increase in telemedicine visits replaced only approximately 40% of the decline in in-person visits during this period.

Notably, the authors observed that patients living in lower-income or predominately non-white zip codes had approximately a third lower increase in telehealth visits than those who lived in the wealthiest neighborhoods.

"The extent to which access barriers to telemedicine contribute to lower rates of in-person care deferral, and thus increases in potential exposure to COVID-19, should be examined in future work," Whaley said in the press release.

Health care use drops during pandemic; switch to telemedicine creates disparities. Rand Corporation; November 5, 2020. 

https://www.eurekalert.org/pub_releases/2020-11/rc-hcu110320.php

During the first 2 months of the COVID-19 pandemic, many Americans reduced their in-person preventive and elective health care visits and increased telemedicine appointments. 

Telemedicine Use During the First 2 Months of the Pandemic Did Not Offset the Drop in In-Person Visits

Alana Hippensteele, Editor

Since 2000, nurse practitioners have enhanced the availability and quality of primary care for Americans, especially aging baby boomers. However, if the primary-care health care delivery system remains fundamentally unchanged through 2020, experts project a shortage of 20,400 primary care physicians. The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30%, from 55,400 in 2010 to 72,100 in 2020. With proper integration of NPs and physicians’ assistants into our health care system, the physician shortage will shrink to about 6000.

Full prescriptive authority lets NPs integrate properly into the health care system.

Nurses’ roles began evolving during the Vietnam War in the 1960s, when concerns about the delivery of primary health care initially arose. The role continued to progress through many different certifications before NPs, such as certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists, became commonplace. These elevated roles existed mainly in acute inpatient settings and specialty units.

For NPs to practice most advantageously, they must have prescriptive authority, promulgated in state scope of practice laws as 2 distinct types: authority legislated by regulations or nursing statutes, and delegable authority.

The types of prescriptive authority permitted in nursing legislation are further broken down into 2 categories: dependent authority, under which physicians must cosign the order, and independent authority, under which NPs can prescribe alone.

Results of a study, conducted in North Carolina, showed that NPs with full prescriptive authority provide cost-effective care with high-quality outcomes.

Delegable authority mandates an initial patient-physician relationship. It is further broken down into 3 categories: physician determination of patient-specific medications, prescription renewal by the nurse, and standing order/protocols.

Barriers to full prescriptive authority come from federal and state legislature, and organization’ business structures. For example, under Medicare’s Physician Fee Schedule, NP services are paid at 85% of the physicians’ rate, which financially gives primary care practices an incentive to bill under the physician’s name. Additionally, federal regulations require physician cosigners on home care service orders. At the state level, 29 states still restrict NP practice and/or prescriptive authority by requiring collaborative relationships or physician supervision. Organizationally, in the primary care setting, physicians can employ medical assistants (MAs) to help support their practices, but NPs cannot. Results from a 2014 study showed that patient cost was cut by 9% to 12% if NPs could hire MAs as supportive personnel in primary care.

In 2016, the Department of Veteran Affairs (VA) issued a rule giving full practice and prescriptive authority to NPs. Even in states requiring physician supervision, NPs at the VA can practice with full practice rights within the scope of their VA employment.

NPs employed in pediatric intensive care units (PICUs) are also front-runners. In a 2017 national survey of 112 PICU medical directors of various organizations, 49% reported that NPs have full practice authority, and 73% reported that NPs have prescriptive authority in line with state laws.

Joy Elwell, director of the doctor of nurse practice program at the University of Connecticut in Storrs,said it best: “In all 50 states and 5 districts, NPs have some level of prescriptive authority.”

These levels are restricted by the state’s individual scope of practice, as noted above. Today, 23 states and the District of Columbia allow full practice authority, independent of physicians’ collaborative/supervision agreements. The most recent state to give NP full practice authority was Oklahoma, in March 2017.

Elwell also said, “As of 2017, NPs in Florida and Georgia can prescribe [some] controlled substances.” The other 27 states require either supervisory or collaborative practice.

“In general, the Northeast [Connecticut, Maine, New York, and Vermont], Northwest [Nevada, Oregon, Utah, and Washington], and Southwest [Arizona, New Mexico, and Wyoming] have excellent scope of practice laws,” Elwell said. “They give NPs practice and prescriptive authority equal to physicians. In the Southeast, the laws are less favorable. NPs can diagnosis, treat, and prescribe, but they must do so under supervisory/ collaborative practice with physicians.”

One of the most restrictive states is Alabama, Elwell said.

Alabama’s scope of practice law states that the supervising physician in a collaborative practice must be on-site 10% of the time. Parts of Alabama are extremely rural, and the collaborating physician may need to travel long distances. If the physician fails to arrive at the clinic, the state will close the practice, and suspend the NP’s license. Many times, the area has no other primary care practice, so patient care suffers. California, Massachusetts, New Jersey, Ohio, Pennsylvania, and Texas, among others, which have restrictive scopes of practice, have bills in their state legislatures to grant full prescriptive authority (Figure).

Patients, payers, and pharmacists tend to accept NPs without pushback.

“The American Medical Association [AMA] exerts pushback on a national level,” Elwell said. “Politically, the AMA says that physicians should resist legislation that promotes NP scope of practice.”

However, most local physicians disagree because they want to help provide health care to the 300 million-plus Americans.

The American Association of Nurse Practitioners is lobbying for change at the national level and supporting state-specific efforts. Each state also has its own NP association pushing to advance practice.

NPs have made great strides toward full practice, and prescriptive authority over the past 2 decades. Advocates, such as Elwell, think that over the next 10 years, more than 30 states will change their scope of practice laws to allow NPs to have full practice authority. As our population ages, and more people have access to health care, Americans will need NPs backed by advanced education and law to provide much-needed health care.

For updates on the different states’ scope of practice, visit

scopeofpracticepolicy.org/practitioners/nurse-practitioners

Alexandra R. Cambra, PharmD, is a graduate of the University of Connecticut in Storrs and works for CVS.

Health Resources & Services Administration. Projecting the supply and demand for primary care practitioners through 2020. bhw.hrsa.gov/health-workforce-analysis/primary-care-2020. Updated October 2016. Accessed April 10, 2018.

Edmunds MW, Cawley J. Historical review of prescriptive authority: the role of nurses (NPs, CNMs, CRNAs, and CNSs) and physician assistants. Basicmedical Key. basicmedicalkey.com/historical-review-of-prescriptive-authority-the-role-of-nurses-nps-cnms-crnas-and-cnss-and-physician-assistants/. Published July 22, 2016. Accessed April 10, 2018.

Conover C, Richards R. Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.

. 2015;63(5):585-92. doi:10.1016/j.outlook.2015.05.009.

Poghosyan L. Federal, state, and organizational barriers affecting nurse practitioner workforce and practice.

Gigli KH, Buerhaus PI, Minnick AF, Dietrich MS. Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.

Journal of the American Association of Nurse Practitioners

The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30% in 2020. Full prescriptive authority lets NPs integrate properly into the health care system. 

Authors