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Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Contributing EditorIndividualAuthor
To the Editor: The study by Dr Mundinger and
colleagues1 compared the health outcomes
of patients treated by nurse practitioners to those treated by physicians
in primary care settings that were similar in terms of responsibilities and
patient panels. There was no description of the training of either the physicians
or the nurses in the study, other than that they were all faculty members.
The authors state, "The combination of authority to prescribe drugs, direct
reimbursement from most payers, and hospital admitting privileges creates
a situation in which nurse practitioners and primary care physicians can have
equivalent responsibilities." This combination does not include core elements
of medical care such as evaluation, diagnosis, and treatment of undifferentiated
patients. Patients with previously diagnosed and treated asthma, diabetes,
and hypertension could be cared for successfully in a limited time frame by
a person with less training than a physician. Each of these conditions has
very clear treatment guidelines.
The most troublesome aspect of the study is the outcome measure. Although
the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) is a well-established
measure of health status, it assesses only self-reported perception of health.
Furthermore, the sensitivity of the SF-36 for detecting longitudinal change
within patients has been questioned.2 Patient
satisfaction may be important but in itself is not a measure of the ability
to provide many of the complicated aspects of patient diagnosis and care.
In the accompanying Editorial,3 Dr
Sox states that the study has strong internal but weak external validity,
and thus the conclusions of this study cannot be generalized. They are highly
limited to this particular patient population and clinical structure and the
relatively brief period of this study.
Bagley B. Health Outcomes Among Patients Treated by Nurse Practitioners or Physicians. JAMA. 2000;283(19):2521–2524. doi:10.1001/jama.283.19.2521
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