Does Prescribing Differ by Discipline?


Researchers from the Johns Hopkins Bloomberg School of Public Health acknowledged that nurse practitioners and physician assistants have growing roles and increasing prescribing authority in the nation.

In 2015, an article published inForbesreported that although health systems have traditionally placed physicians, and especially family medicine physicians, high on the labor demand scale, the landscape was changing.1According to the article, health systems were increasingly more likely to look for nurse practitioners (NPs) and physician assistants (PAs) to fill critical roles. Physicians remained a primary need, but NPs and PAs both appeared in the top 20 of most in-demand health professionals, with NPs occupying position #6 and PAs in position #11.

Researchers from the Johns Hopkins Bloomberg School of Public Health have acknowledged that NPs and PAs have growing roles and increasing prescribing authority in the nation. As prescriptive authority has broadened across the nation, little data has been available comparing prescriptive quality.

The researchers conducted a study to compare the quality of physician, NP, and PA-generated prescribing.2Using a serial cross-sectional analysis design, they sampled 701,499 patient visits between 2006 and 2012. This sample extrapolated to 8.33 billion health care visits.

Physicians provided the lion's share of health care (96.8%) and nurse practitioners and physicians assistants accounted for 1.6% each. The researchers examined 13 quality indicators across a range of chronic diseases. They also examined antibiotic use and concurrent prescription of contraindicated medications.

Across disciplines, only approximately one third of patients with congestive heart failure received ACE inhibitors in accordance with commonly accepted guidelines. This was a significant gap in care. Patients were as likely to receive (or not receive) ACE inhibitors if they saw physicians, NPs, or PAs.

Other areas where prescribers were unlikely to comply with guidelines included beta blocker use for coronary artery disease, selected antibiotic use for acute otitis media, depression treatment, inhaled corticosteroids for asthma and adults, and statin use. In all of these areas, approximately half of prescribers were nonadherent with evidence-based guidelines.

Prescribers were likely to adhere to guidelines for a number of other conditions, with overall adherence close to 90% for antithrombotic therapy in atrial fibrillation and avoiding benzodiazepine use for depression. All 3 types of health care professionals did a good job of avoiding inappropriate medications in older patients.

The researchers concluded that the quality of prescribing was similar across the board. There is certainly room for improvement in all of these indicators, but no one discipline was more likely than another to be nonadherent with guidelines.

This study differs from previous studies in that its statistical power was quite high. The researchers confirmed the hiring trends reported inForbes, stressing that NPs and PAs continue to be one solution to physician shortages. Studies like this provide support for growing autonomy and prescriptive authority, the researchers noted.

This study appears in the journalPharmacotherapy.


  1. Japsen B. Nurse practitioners more in demand than most physicians.Forbes. Published July 15, 2015. Accessed February 22, 2018.
  2. Jiao S, Murimi IB, Stafford RS, et al. Quality of prescribing by physicians, nurse practitioners, and physician assistants in the United States.Pharmacotherapy.2018 Feb 19. doi: 10.1002/phar.2095. [Epub ahead of print]

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