Background:
Recently, the role of non-physician extenders such as nurse practitioners has expanded in the hospital setting. However, there are few data examining the consequences of adding these providers to the care provision team. The primary aim of this study was to determine the effect on quality of care and hospital efficiency of adding nurse practitioners to patient-care teams.
Methods:
A quasi-randomized, controlled trial enrolled adult patients admitted by private physicians (without housestaff or non-physician providers) to a general medical-surgical unit in an academic medical center from March 1, 2014 to October 31, 2014. As per hospital policy, the admissions department randomly allocated patients to beds on the unit, and nurse practitioners were then assigned to cover consecutively numbered beds until their case-load was reached. Hospital administrative databases were analyzed to measure length of hospital stay, in-hospital mortality, cost of admission, 30-day readmissions, transfer to a more intense level of care, and time of day discharge order was written. Length of stay and costs were log transformed due to skewness and geometric means are reported.
Results:
Of the 382 patients included in this study, 263 were assigned to the nurse practitioner group. Baseline characteristics were similar in both groups. Hospital mortality was lower in the nurse practitioner group (odds ratio (OR) 0.11; 95% confidence interval (CI) 0.02 to 0.51). Patients cared for by the nurse practitioner were also less likely to be transferred to more intensive care (OR 0.39; 95% CI 0.20 to 0.75) than those without nurse practitioner coverage. However, patients in the nurse practitioner group had an increased length of stay (geometric mean=5.80 days for nurse practitioners, 3.63 days for no nurse practitioners; p<0.0001). Additionally, the cost of admission per patient was higher for those assigned to the nurse practitioner group (geometric mean=$6,631 for nurse practitioner, $5,121 for no nurse practitioner; p=0.005). There was no statistical difference for 30-day readmission between the groups, nor any differences in the time discharge order was written. The results were unchanged when models were run to adjust for potential confounding.
Conclusions:
The addition of nurse practitioners to a medical-surgical unit yielded lower hospital mortality and fewer transfers to intensive care, but this was associated with longer hospital lengths of stay and higher costs. Larger randomized studies are needed to confirm the impact on clinical outcomes and to determine the cost-effectiveness of utilizing nurse practitioners for hospitalized patients.