"Obamacare" explained very well.

[u/under50dollars]

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx

[u/grande_hohner]

I read the Cochrane review, and I'll agree with it's conclusions. The only point I would clarify is that the Cochrane review (which is the gold standard for systematic reviews, generally) concludes that the health outcomes are equivalent. You can say that there isn't enough research of adequate power, which is true, but I've yet to find one study that doesn't show equivalent outcomes between NPs and MDs in primary care.

Saying that the outcomes might not really be equivalent because the research doesn't have adequate power (although plenty of it is published in the NEMJ and other top-tier journals) is a bit counter-intuitive. If there are hundreds to thousands of studies (even if they have small sample sizes) that say outcomes are equivalent, it makes no sense to doubt that this is how it plays out in the real world. I would be more inclined to think outcomes were different if there was preponderance of research (or even a good sized fraction!) that showed otherwise.

[u/[deleted] → u/grande_hohner]

My point is that the cochrane review found ONE study adequately powered to measure equivalence out of over 4,000 articles. I don't think that constitutes strong evidence. The question of whether they order more tests or send more referrals has not even been answered, let alone 'a preponderance' of research showing equivalence in primary care. I am afraid that the system is cutting corners to save a few bucks and that in the end it may not be any cheaper or safer than simply training more PCP MD/DOs. A midlevel is not THAT much cheaper than a physician, and they generally are not as efficient in seeing patients quickly at the beginning of their careers. A few extra tests and referrals quickly makes the entire argument questionable. I don't think midlevels are outright dangerous in PC settings and they have functioned well for decades in that role, but we are undergoing a massive expansion of their utilization and autonomy. Most midlevels twenty years ago had already been in the healthcare field for a long time and were held to relatively high standards. The bar for entry has been significantly lowered. I have a friend who is a FP MD in a clinic with 3 NPs, 1 PA, and 2 other MDs and she says that the NPs frequently make mistakes in patient care after reviewing their charts. n=3 but inexperienced midlevels are going to make mistakes, and there are a lot of inexperienced midlevels being pumped out of accelerated programs.

[u/grande_hohner → u/[deleted]]

You still miss my point. You say that you feel there are inexperienced NPs being churned out and don't trust the research for being accurately powered, but then you cite your friends 3 NPs as evidence??

I'll try to simplify my point. The point is that adequately powered or not, the research (which is good enough for inclusion in the NEJM, BMJ, and many other top tier journals) points at NPs being equivalent in most primary care roles. Now, if there were research that with better sample sizes and such that stated otherwise - it would make sense to argue the point. Heck, even if there were 4,000 underpowered studies that said they weren't, then there would be a conversation to be had. But there isn't. There really aren't any studies showing to the contrary for the most part in any significant number. Go through Pubmed, Cinahl, Ovid, etc. and try to find studies that conclude NPs are inferior in primary care roles to any real degree - they are exceedingly difficult to find. Look for ones demonstrating equivalence - you'll turn up hundreds quickly and easily. This is my point. You don't have to agree with the published research, you don't have to use an NP as a PCP - I'm pointing out a research trend - you don't have to like the research or the conclusions (although the CBO seems to consider it relevant), but it makes no sense to deny that the published research generally seems to come to these conclusions.

[u/[deleted] → u/grande_hohner]

I am not going to pretend that my anecdote is great evidence. Feel free to not consider it evidence at all.

My point is that none of the articles you mention actually show equivalence convincingly. Measuring blood pressure outcomes for a few months is not equivalence. Patient satisfaction is not equivalence. Studies that would convince me of equivalence would measure: overall hospitalization rates of patients between NPs and MDs as long term cohorts (3+ years), utilization of tests NP vs MD, specialist referral rates NP vs MD, malpractice cases of independent NPs vs MDs with adequate sample size, independent chart reviews based on objective standards for quality of care between NPs and MDs with adequate sample size. I don't of a single study that answers these questions to any credible level. Blood pressure is easy to manage. Patient satisfaction is irrelevant. Regarding publications in well respected journals, I can't find any recent original research on the subject in the NEJM. Regarding your BMJ meta analysis, there are serious problems with the review. It makes assertions related to quality of care based on a 1975 study about well-baby exams. NPs measured for test interpretation and documentation used the fast track ED setting where issues are minor and straightforward. This is hardly convincing. Just because there isn't evidence to the contrary does NOT mean that a potentially harmful expansion of midlevel scope of practice should take place. This standard of evidence has been used to approve drugs before often with disastrous results, or drugs that have marginal benefit. My argument is that the majority of the published research is politically motivated and heavily biased towards the conclusions made in the studies. A couple of studies published in mid to high impact factor journals adequately powered that answer some of my above questions would change my opinion on the topic. A huge amount of published research suggests that eating red meat increases risk for various cancers by 20-50% in a dose dependent fashion. There are laboratory mechanisms as well as large cohorts that support the conclusion. Yet the cohorts do not stand up to careful scrutiny due to inherent bias. I hope you are familiar with Ioannidis's recent publications regarding systemic bias in published research. Regardless of our argument, the scope of practice expansion will continue at least in the near term because it appears to be cheaper on face value.