NPs, physicians appear equally likely to prescribe potentially inappropriate medications to seniors

Nurse practitioners (NPs) and physicians are similarly likely to prescribe potentially inappropriate medications to older patients, a new study found.

The study, which assessed prescribing patterns of 23,669 NPs and 50,060 primary care physicians, included clinicians who wrote prescriptions for at least 100 patients per year. Researchers looked at 760 million prescriptions for Medicare Part D beneficiaries ages 65 years or older from 2013 to 2019. Prescriptions were deemed potentially inappropriate if the American Geriatrics Society's Beers Criteria recommended against their use. Clinician prescribing rates were adjusted for practice experience, patient volume and risk, clinical setting, year, and state, researchers wrote. The study was published on Oct. 24 in Annals of Internal Medicine.

The average rates of inappropriate prescribing were “virtually identical” between the two groups (adjusted odds ratio, 0.99; 95% CI, 0.97 to 1.01; crude rates, 1.63 per 100 prescriptions by NPs vs. 1.69 per 100 by physicians; adjusted rates, 1.66 vs. 1.68). However, the “averages mask substantial underlying differences in inappropriate prescribing patterns,” as data showed NPs were overrepresented among those who consistently adhered most to the criteria, and those who adhered least to the criteria, said the study authors.

Ten medication classes made up 99.5% of all inappropriately prescribed medications: antidepressants, muscle relaxants, hypnotics, generation 1 antihistamines, sulfonylureas, barbiturates, antineoplastics, thyroid medications, and NSAIDs. The majority of NPs were women (89%) compared with 39% of primary care physicians. Researchers also found NPs had fewer years of practice experience than physicians, on average. Compared with physicians, NPs treated fewer older patients on average (199 vs. 272 per year). On average, NPs wrote significantly fewer prescriptions for this population (1,271 vs 3,800) and were more likely to practice outside large metropolitan areas than primary care physicians.

“Our findings regarding patterns of inappropriate prescribing among NPs and primary care physicians have useful lessons for policymakers, lawmakers, and regulators,” the study authors wrote. “If expanding patient access while ensuring quality and safety systemwide 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.”

An accompanying editorial echoed this sentiment. “Whether the prescriber is an NP or a primary care physician matters far less in shaping prescribing behavior than numerous other factors,” the editorial said. The study's analyses indicate that NPs are seeing more older adults outside large metropolitan areas, many of whom would probably have no other source of primary care, the editorialists noted. “There are nearly 100 million persons living in 8267 health professional shortage areas in the United States where there are insufficient primary care providers to meet health care needs. Nurse practitioners will continue to serve critical roles in ensuring that older adults in areas with inadequate numbers of health care providers receive primary care,” the editorialists wrote. “Our goal should be to reduce variation and improve prescribing quality among all clinicians who care for older adults.”