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Stanford Medicine Study Challenges the AMA’s Fight Against Scope Creep

Gayle Morris, BSN, MSN
Updated November 27, 2023
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    A study from Stanford Medicine reveals that NPs are as safe as MDs when prescribing medication to older adults. Learn what one NP has to say.
    Nurse administering medication to senior manCredit: Getty Images/iStockphoto
    • A study from Stanford Medicine finds that NPs are as safe as MDs in prescribing medication to older adults.
    • The American Medical Association is strongly opposed to nonphysicians prescribing medication — an act they characterize as scope creep.
    • The study concluded it would be more impactful to patient care to address deficient performance no matter who is prescribing.

    Currently, nurse practitioners have full practice authority in 27 contiguous states and Hawaii, Alaska, Guam, and the Northern Mariana Islands. In these states, NPs manage patient care, including prescribing medication and controlled substances, without physician oversight.

    Full practice authority has not been well-received by all medical professionals and organizations, including the American Medical Association (AMA), which uses the term “scope creep” to describe the idea of full NP practice authority. Let’s dive into the AMA’s objections and the most recent data revealing that NPs are as safe as physicians when prescribing medication to senior adults.

    The Fight Against Scope Creep: The AMA’s Recovery Plan for Physicians

    The AMA developed a “Recovery Plan for American Physicians” that includes addressing the overuse of prior authorization, supporting telehealth, reducing physician burnout, reforming the Medicare payment system, and fighting scope creep.

    According to the AMA, scope creep describes the “expansion of the medical services and procedures nonphysician health professionals are allowed to perform.” The AMA continues that “allowing nonphysicians such as nurse practitioners (NPs) or physician assistants to diagnose and treat patients without any physician oversight is a step in the wrong direction,” and the best way to lower costs and improve care is for physicians to be leaders of the healthcare team.

    The AMA’s stated position is, “Patients deserve care led by physicians — the most highly educated, trained and skilled health care professionals. That’s why the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety, and it’s why fighting scope creepis a critical component of the AMA Recovery Plan for America’s Physicians.

    Study Finds NPs Are As Safe as Physicians in Prescribing Medication to Older Patients

    In response to initiatives like the AMA’s, and to provide more representative data for legislators, policymakers, and regulators, researchers at Stanford Medicine conducted a study — the largest of its kind — to analyze the prescribing patterns of nurse practitioners and physicians in states where nurse practitioners had full prescriptive authority.

    Researchers gathered data from more than 73,000 primary care physicians and nurse practitioners, analyzing prescribing patterns for Medicare beneficiaries aged 65 years or older from 2013 to 2019. They calculated the rate of inappropriate prescribing according to Beer’s Criteria developed by the American Geriatric Society.

    “Older adults account for a huge proportion of all prescriptions written,” said senior author David Studdert, LLB, ScD, a professor of health policy and law. “They are also especially vulnerable to adverse drug events from inappropriate prescribing.

    According to the study’s results, “Nurse practitioners were no more likely than physicians to prescribe medications inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.”

    How Nurse Practitioners Feel About Scope of Practice Limitations

    Seana Rutherford MSN, APRN, FNP-C, CWS, is a nurse practitioner with privileges at Cleveland Clinic’s Fairview Hospital who owns her own practice. She recently spoke with NurseJournal about the results of the Stanford Medicine study.

    “I’m passionate about our profession. I’m not surprised by the results of the study. It’s not a good look for NPs to be at the top and bottom of the evaluation. Physicians are my peers. It’s been hard-earned respect from these guys,” she said.

    The inability to practice to the full extent and capacity of their licensure could create inefficiencies and restrictions to healthcare. A 2021 paper analyzed a data set of electronic health records and claims to quantify the effect of increasing the scope of practice laws. They found that when NPs were granted greater authority in the state, there was some evidence that NPs began practicing more autonomously. Yet, there was no evidence that it changed the volume or allocation of patients to NPs within large practices.

    In other words, even with greater authority, NPs tended not to open their own practices. The limits and boundaries states set on the care NPs are allowed to independently deliver can limit high-quality, accessible care to patients as there is also a physician shortage that limits access to healthcare.

    Rutherford talked about how operating under reduced practice authority in Ohio impacted patient care, including the ability to prescribe medications.

    [that I can] write a prescription in the hospital but not in my office.”

    How Greater Prescriptive Authority Could Impact Healthcare

    The American Medical Association has expressed concerns that expanding the scope of practice for advanced practice registered nurses is a bad idea that could lead to higher healthcare costs and reduced safety for patients.

    “Patients are better served when all members of the health care team share information and decision-making based on their unique skills — all with the common goal of improving the health of the patient,” AMA President Susan R. Bailey, MD, told the Nebraska APRN Technical Review Committee.

    “Expanding the scope of practice of APRNs to allow independent practice and prescriptive privileges will increase utilization of diagnostic services, antibiotic prescribing, and opioid prescribing — all of which can take a real toll on health care costs as well as threaten the health and safety of patients,” Bailey continued.

    However, Stanford Medicine researchers believe that opening the door to greater prescriptive authority across the U.S. could have a positive impact on healthcare:

    “If expanding patient access while ensuring quality and safety system-wide is the goal, fixation on the question of whether NPs or other nonphysician providers should be allowed to prescribe may be less impactful than identifying and addressing deficient performance among all clinicians who prescribe, regardless of practitioner type or practice location,” the researchers wrote.

    Rutherford agrees that the healthcare system should focus on patient safety, no matter who is delivering care.

    “We should have a support system built within the healthcare system for NPs and MDs. There should be a system for checking prescriptions so NPs and physicians have a hard stop, whether that’s in a computer system in the hospital or the pharmacy,” she said.

    Meet Our Contributor

    Portrait of Seana Rutherford MSN, APRN, FNP-C, CWS

    Seana Rutherford MSN, APRN, FNP-C, CWS

    Seana Rutherford began her nursing career as a registered nurse in 2011. In 2015, she graduated with honors from Ursuline College, earning an MSN with a focus in family practice. She has been a certified nurse practitioner since 2015 and founded her own private practice, Lake Effect Health, in 2018. She has practiced in a variety of care settings, including primary care. She is also a certified wound specialist (CWS) under the American Board of Wound Management. Seana maintains privileges at the Cleveland Clinic’s Fairview Hospital and has recently completed her doctor of nursing at Ursuline College, where her work focused on pressure injury prevention in long-term care facilities.